Book Review: The Body Keeps the Score
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This seems like a problem with the APA. Why would they categorize around symptoms? The same symptoms can have different root causes and would then require different treatments. So doesn't it make sense to categorize around root causes?
The rest of medicine seems to be more concerned with causes. A sore throat might be a cold, or it might be cancer. Obviously they require different treatments, so they don't lump them all into "sore throat" and do the same thing every time there's a sore throat.
Likewise if someone exhibits the symptom of ADHD and the cause is "Bad Genes" but you're trying to treat them for non-existent trauma, it doesn't seem like it's going to be effective.
Because the APA is well aware that for many if not most psychiatric illnesses they are at the “fever” level of specificity in diagnosis, not “malaria” or “influenza”. But they have treatments that work for fever and very limited insight into the etiology of the diseases they work with.
> The same symptoms can have different root causes and would then require different treatments. So doesn't it make sense to categorize around root causes?
If they could they would. I’m sure there are examples of where a single psychiatric illnesses’ etiology has been uncovered and then they’ve broken it out into its own thing, and recommended the specific treatment for it that reliably works.
If ones interest is in research and understanding underlying causes some of the symptomatic categories are not helpful. People pushing the boundaries of knowledge have to structure these domains and will come up with new terminology. This terminology will not easily map to the symptomatic view.
The rest of medicine may look like being interested in root causes. And where there is easy and accurate tests available that is true. There are areas in medicine where knowledge is limited and treatment is symptom focused.
AMA's approach is middle age - but our knowledge is on middle age level compared to what we know e.g. how muscles work. In psychiatry there is a huge gap and misdiagnosis is very common and does real damage. To compound the issue diagnosis is linked to insurance payments which considering the fuzziness of knowledge frankly scary.
I don't think much progress comes from restructuring or optimizing existing categories and labels. What will have an impact if we got a sufficiently large set of more narrow conditions with reliable tests. Then the old system will be swept away. Until then it will be hit and miss and the best one can hope for is an educated counterpart who is keeping an open mind and is able to observe well.
Oftentimes the root cause in medicine is something we can't fix, and sometimes something we can't even identify. Biology's the domain of complex causes, where few things have a single cause and a lot of things are interlocking systems governed by homeostasis.
I feel like I've wasted years and a lot of money with psychotherapists who insist on bullshit root causes.
Treating symptoms allows you to break the problem into smaller issues, monitor progress, change course and so on.
There is no treating "root cause" -- the root cause happened dacades ago; it allows lousy psychotherapists to continue to be lousy psychotherapists.
There is no way to objectively quantify the root cause and to train psychotherapists to "treat the root cause".
The "treat the root cause" psychoterapies, starting with psychoanalisis are just bullshit psychotherapies, no better than the "detoxifying" and "holistic" diets.
Discussion: https://news.ycombinator.com/item?id=21340636
The perspective of being able to debug your own brain is invaluable and understanding other methods to do the same are worth the price of the book.
Buy an electronic and paperback. Great book.
Namely, that your mental health is part of your body, not part of your mind.
It really changed my perspective, where before I had contempt about my body, saw it as a nuisance, I now understand I -am- my body. It's as much a part of me as my mind.
It helped me look into the right direction for treatment and additional resources.
There were parts of my behaviour that held me back, but I thought were crucial to my identity so I was reluctant to let them go. After I realised that they were symptomatic of psychological injury and not part of my fundamental identity, I allowed the change to happen.
It felt more like going through a process of healing in the same way that I might treat a muscle strain, and not spend the rest of my life limping because of a bad fall.
I realise that sounds a bit contradictory - I guess the idea is that my mind is part of body and can be treated as such, which makes it necessary to liberate the ego from the rest of the mind. It made the concept of mindfulness finally click for me.
TL/DR- he's mostly critical of the book, but provides this update:
>[Update, written a few weeks after the rest of this post: maybe it is all wizardry. I recommended this book to a severely traumatized patient of mine, who had not benefited from years of conventional treatment, and who wanted to know more about their condition. The next week the patient came in, claiming to be completely cured, and displaying behaviors consistent with this. They did not use any of the techniques in this book, but said that reading the book helped them figure out an indescribable mental motion they could take to resolve their trauma, and that after taking this mental motion their problems were gone. I’m not sure what to think of this or how much I should revise the negative opinion of this book which I formed before this event.]
- Within a week he seems to have found that the content of the book was more effective than years of his treatment of atleast one patient
- He buries this as deeply within the article as possible
- This experience casts light on the crux of my issue with the article, which is that it is very much a "prereplication" book review.
The reality is that neither the author of the book or the review have solid empirical evidence one way or the other, in terms of modern style studies. The book review seems to be drawing an overly negative conclusion about the research because of this fact. To me this is a demonstration of an overreliance on empiricism that seems to dog alot of western medicine practitioners in general.
I found this line very revealing:
>later studies – done in an atmosphere of boredom, by large multi-center consortia – are almost always disappointing.
I'm not sure what the phrase "atmosphere of boredom" signifies but it doesn't sound like a faithful attempt to get something to work. If you are doing any of these treatments in an atmosphere of boredom will it actually be effective? Is doing it in an atmosphere of boredom really a valid way of testing it?
I haven't read the book but will read it. It does seem to me that the thesis of the book, that trauma causes the mind to disconnect from the body and shapes the body, is something that Chinese medicine / Qi Gong practitioners have known about for thousands of years. I don't have any empirical evidence to back these specific practices but I have mountains of anecdotal evidence that would seemingly be rejected by the author of the review.
If you have a broken bone, it doesn’t matter how bored the nurse who sets your cast is - as long as they follow established procedure, you have an extremely high chance to make a good recovery.
The issue with psychiatry is that it doesn’t really follow that model for many (most?) “conditions”. As the author points out, wild new approaches seem to work when everyone is excited about them, and then fail to do much better than a placebo when scaled out.
You've raised a good point that this makes it even harder to determine how well something is working. Was it 100 percent placebo or did change take place outside of the effect of the placebo?
However just because the placebo effect is present doesn't mean we should dismiss it out of hand.
The term "scaling out" and a "boring environment" to me requires a treatment as simple as for instance setting a broken bone. A procedure like this is very easy to train someone to perform and there is relatively little in the way of differentiation between patients. An arm is an arm, it's very easy to see the problem as well as to see how a treatment is working.
But for instance in the case of acupuncture or qi gong or yoga, it would be very hard to replicate on a large scale. The practitioner matters a huge amount, as does the exact condition of the patient. Is the patient actually trying ot do the yoga? Is the acupuncturist good (most aren't). What kind of yoga is the person doing? Is the yoga or qi gong teacher leading them in the right direction for their particular issue? It isn't nearly as simple as a routine medical procedure.
I'm not saying that all of these treatments necessarily are effective. The issue I have is how quickly some are to dismiss treatments as not being backed up by evidence when the evidence will be very hard to come by, and ignoring the nuance involved. Personally my experience has led me to believe that acupuncture done by someone that knows what they are doing will work more than a placebo. The same certainly goes for qi gong in my personal experience.
This would seem incredibly low, even for a non-expert. At the time, as the article notes, there were 100 million women in the US - for incest to only impact 100 women in the country and yet be something that there is a word (noun) for, laws against, and historical records of stretching back millenia stretches credibility, surely.
It's a bit like global warming denialism. Admitting that child abuse within families is not extremely rare has absolutely horrifying implications for people's moral universes. Much easier to deny it happens.
> [Update, written a few weeks after the rest of this post: maybe it is all wizardry. I recommended this book to a severely traumatized patient of mine, who had not benefited from years of conventional treatment, and who wanted to know more about their condition. The next week the patient came in, claiming to be completely cured, and displaying behaviors consistent with this. They did not use any of the techniques in this book, but said that reading the book helped them figure out an indescribable mental motion they could take to resolve their trauma, and that after taking this mental motion their problems were gone. I’m not sure what to think of this or how much I should revise the negative opinion of this book which I formed before this event.]
"We have some treatments; they seem to work sometimes, although we don't really understand why and they're not entirely reliable" is still a far better place than "we have no treatments", which in turn is far better than "your condition does not exist and you are lying". I feel slightly better about SSC for admitting this and being willing to carry on working in an uncertain environment.
I still would hesitate to recommend a psychiatrist's services to anyone without an extensive disclaimer, though. [In a way that I wouldn't with a general practitioner, or even a talk therapist.] It would be great if that changed one day.
I've also noticed - both personally and from talking with others - that a disturbing number of practitioners in this field seem to lack empathy and/or professionalism, which in my view are absolutely critical when dealing with mental health issues.
Other end of the spectrum: the human mind is such a weird complicated thing that it is ultimately impossible to build a systematic discipline that can effect meaningful change in what a particular cultural context considers a mental/behavioral “disorder”.
The hyper rational, scientific part of me hopes for the former; but having worked a lot in education, particularly with children/teenagers who had suffered trauma/were actively suffering trauma, the latter feels truer to my gut.
I'm not sure of the author is purposefully ignorant about this, but the original ACE study was done on middle class households, 75% white. https://www.npr.org/sections/health-shots/2018/09/17/6487108...
Only from the myopic perspective of people only used to a life of luxury and ease.
Throughout most of history several of the people most close to you would have made an early and often quite unpleasant exit before you reached adulthood -- most of your siblings and children would probably not make it into adulthood and women had a double digit chance of dying from child birth[1]. And that held true even if you were an affluent member of a relatively stable and successful society.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1139114/pdf/med...
So a priori it seems extremely unlikely to me that severely unpleasant experiences have psychologically crippling effects on a majority of people. Because that would seem to be extremely maladaptive for almost all of the last few millenia.
The same holds true for modern lead pipes. They work fine, until they don't.
https://westhunt.wordpress.com/2018/08/18/ptsd/
then again, from what we can tell about the premodern world it seems much more violent than what we are accustomed to.
I dunno, man. If you want to take seriously some dude who builds a house of cards from incredibly tendentious evo-psych nonsense so he can scale it to the dizzying heights of "this is why all gay men lisp", you do you.
[1] https://web.archive.org/web/20081011094900/http://zero.poynt...
Dr. Cochran thinks that gay men lisp because a pathogen has affected their brains. But most gay men don't lisp. It was only ever a cultural thing, it was never universal, and it's mostly gone out of fashion in the last few decades.
He says that preferential male homosexuality has only been observed in humans and sheep. This is utter bullshit. Homosexuality has been observed in hundreds of species, including primates, mammals in general, birds, reptiles, and arthropods. This is not new research: over 450 species were known in 1999.
It goes on and on. This kind of ignorance might have been understandable, if not excusable, in the '70s, but Cochran was writing in 2005. He's making confident scientific assertions based on lazy, decades-old stereotypes, and there's no excuse for that.
To answer your question: no, I didn't read the article, because I read one sentence and concluded that it was horseshit. I should have taken a closer look before commenting, but I've done that now and my first assumption was 100% correct.
you ought to read about toxoplasma if you think complex behavior resulting from pathogen infection is outside the realm of possibility. 'lisp' is not strictly accurate, but gay men cross-culturally tend to particular speech patterns, including over-enunciation of the letter s, even as children; this isn't universal but it's fairly common, and i can't think of a reason that it would result from sexual preference per se.
>He says that preferential male homosexuality has only been observed in humans and sheep. This is utter bullshit. Homosexuality has been observed in hundreds of species, including primates, mammals in general, birds, reptiles, and arthropods. This is not new research: over 450 species were known in 1999.
i looked this up and you skipped over an important qualification: he said "at the-few-percent level". you should really learn to read what you're replying to.
It is conceivable that a pathogen could alter speech patterns, yes. My point was that if Cochran thinks all or most gay men have a distinctive lisp, then at least half his understanding of gay men is based on locker-room rumors and stereotypes. If he can't be bothered to educate himself on those basics, it calls his entire article into question.
If that were that were my only issue with Cochran's article, it would still just be a nitpick. But he gets everything wrong:
> among the Kalahari Bushmen, there doesn't seem to be any at all. Typically, hunter-gatherers have trouble believing that homosexuality actually exists.
There is native Bushman rock art explicitly depicting male homosexuality. See Boy-Wives and Female Husbands: Studies of African Homosexualities, published in 2000. Lots of extremely conservative/traditional cultures will tell you that none of them are queer, despite all evidence to the contrary.
> increased neuroticism and depression
Yes, gay men are prone to depression and emotional trauma. There's been quite a lot of research done on the causes. It mostly concludes that, surprise, they get depressed because they're discriminated against.
> the idea that male homosexuality is caused by a pathogen makes good evolutionary sense, unlike every other explanation ever proposed.
I'll just give you the link. Note the 2004 Italian study, particularly. https://en.wikipedia.org/wiki/Biology_and_sexual_orientation...
> The only two species known to exhibit this behavior, at the-few-percent level, are men and sheep.
Despite your repeating this, it's still bullshit. There are plenty of species with homosexuality rates equal to or higher than humans: giraffes, lions, and elephants, just to name a few.
Any sources I haven't linked here can be easily googled in a few minutes. If you choose to believe that being gay is a disease, nothing I can say will change your mind. Just understand that this is something you believe because it "feels right", not because there's compelling evidence.
Just because someone is surviving and even reproducing doesn't mean they're not psychologically damaged. Even to quite a considerable extent.
Any psychological or physiological damage which doesn't noticeably dent your reproductive fitness, isn't -- at least as far as evolution is concerned. But being a mental wreck along the lines that PTSD is often portrayed very clearly would negatively impact your reproductive success.
There are plenty of people with PTSD who have families (particularly, kids). Our reproductive age begins really, really, really early and our reproductive drive is incredibly strong. I don't know why mental illness like PTSD would in any way impact our ability to procreate as a species or at an individual level. It might make life more difficult and life might be filled with more suffering, but we're able to procreate under all kinds of bizarrely sub-optimal conditions.
One wonders if you could imagine anything that might in any way impact an individual's ability to procreate and have surviving offspring, if you don't see how significantly heightened suicide risk, being volatile and potentially dangerous to be around and restricted in normal functioning might in any way impact an individual's success in having surviving offspring.
> Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens . . . Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.
I took his "self-evident" to be from his point of view as a practicing psychiatrist. Whatever our evolutionary history, lots of people present with it in modern times. For someone who treats such people, once you have the concept for it, it becomes very clear what the disorder is.
This does however not prevent him from then recommending the book to one of his patient whom apparently is instantly cured by it.
Somehow the intro and ending seem at variance with the rest of the piece and I'm not sure your -- plausible -- reading entirely resolves this.
Lots of people presenting with a "disorder" is of course an imperfect indicator that the disorder has some objective basis in fact[1], but there is no real suggestion that Alexander thinks this is the case here. I'm not sure what to make of this piece.
[1] https://en.wikipedia.org/wiki/Koro_(medicine)
> Local official records indicate genital retraction endemics in Hainan Island and Leizhou Peninsula in Guangdong, China, as early as the late 19th century.
The brain is essentially a pattern recognizer in the sense that it will look for danger, and consider ways to avoid the danger.[1]
If we think about the nature of trauma in the past, it has been a society where you are told by your surroundings that things like childbirth indeed is a dangerous but necessary undertaking, supported by the idea that your children will be able to take care of you when you're too old to do so yourself. The pre-modern world was a much more dangerous place due to the lack of modern medicine, et cetera.
Now, in the modern world, the expectations about childbirth have also changed for the better. WHO states that between 2000 and 2017 maternal mortality dropped by 38% worldwide.[2]
Going back to the original argument about PTSD, intuitively it makes sense that if you're subjected to a traumatic experience, your resilience (towards PTSD and other disorders caused by traumatic experiences) are very much affected by the individual's expectation towards the traumatic event. If people go through the event, with the expectation that there is a very probable risk that they will die, it seems there is relief in knowing you survived. On the contrary side, could it be the case that having overly optimistic expectations crushed by trauma, lead to the diagnostic symptoms we associate with PTSD?
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4141622/
[2] https://www.who.int/news-room/fact-sheets/detail/maternal-mo...
In fact, the reason why some people are more resilient to the effects of PTSD than others is already well understood:
"While the presence or absence of any of these responses are not necessarily predictive, people who take a more active, problem-solving approach to the traumatic event are less likely to develop PTSD, while those who dissociate are more likely to develop PTSD."
In terms of selective adaptation, isn't the time scale for human evolution more like 40-50,000 years? IOW, biologically, aren't we living humans the result of evolutionary pressures that predominated in our distant ancestors' lives on the savannah?
US: https://www.pnas.org/content/suppl/2016/05/25/1523592113.DCS... (Table S11)
Taiwan: https://www.sciencedirect.com/science/article/abs/pii/S01602...
Iceland: https://www.dropbox.com/s/9vq5t6urtu930xe/2017-kong.pdf
So what is maladaptive are there breakdown in social ties and cultural/social infrastructure and process for supporting humans going though hell, not, in fact, my PTSD, thanks
Source: https://www.psychiatry.org/patients-families/ptsd/what-is-pt...
Malnutrition says hello. If there is any lesson of history it is "That would be extremly non-optimal of society." is not an arguement against it actually happening. Unless it would leave them literally completely non-viable extraordinarily messed up things can wind up winning out in the circumstances.
A bunch of malnourished farmers who were several inches smaller than their hunter-gatherer ancestors won out against the bands. Despite the obvious disadvantages. Numbers and potentially emplacements allowed the nutritionally stunted to not only win but essentially wipe out hunter-gatherers to the point where they are mostly found where agrarians weren't there to compete.
You might be correct (and one sibling commenter has for example already blamed a change in the availability of social support networks), but it's certainly not obvious to me what the difference might be that suddenly made PTSD a recent "discovery". So I still think it's everything but "obvious in retrospect" in at least one meaning of that phrase.
Maybe it was always with us, and people just failed to recognize it, but naively it would seem that live almost everywhere ought to have been massively more trauma inducing than in the contemporary West.
Second, medical doctors aren’t usually also research scientists. They’re specialists in clinical treatment of physiology. He’s probably smart and well educated. But, not a scientist. As an analogy, it’s similar to when I cringe when I see a programmer try to write a new cryptography protocol or algorithm. Some things are complex and risky enough to leave to the experts.
The reviewer is a doctor and doctors are supposed to be able to understand genetics and read the scientific literature. Maybe not at the same level as a specialist, being able to follow along and tell good science from bad is useful.
As a programmer, I wouldn't be so foolish as to write my own cryptography code, but I understand the basic principles, I do try to keep up, and I expect a researcher writing a book to discuss security issues without dumbing it down too much. If I were reviewing a book saying something about cryptography that seems wrong I would definitely point it out. (Though, not being an expert, it might be in the form of asking questions.)
We can't get anywhere without trusting experts, but that doesn't mean we can't read critically.