> First, I think van der Kolk downplays the importance of the APA’s philosophical commitment to categorizing by symptoms rather than cause. Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor concentration caused by child abuse. Bob has poor concentration caused by bad genes. Carol throws tantrums because child abuse. Dan throws tantrums because bad genes. The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder? Seems sketchy. When the APA decides not to do that, they’re not necessarily rejecting the seriousness of child abuse, only saying it’s not the kind of thing they build their categories around.
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.
> This seems like a problem with the APA. Why would they categorize around symptoms?
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.
A lot of diseases are treated symptomatically. Every time the doctor prescribes aspirin/Tylenol/ibuprofen, rest & fluids, cough suppressants, or anti-emetics, you're treating the symptoms. Rest, isolation, and IV fluids for Ebola is treating the symptoms, and does it very effectively, to the extent that the death rate from Ebola is 10% in developed countries but 80% in the DRC. Psychodynamics, CBT, DBT, and most other types of talk therapy treats symptoms, though I think what we're finding out about the mind is that there's a bit of a causal loop and if you treat the symptoms long enough that is the root cause. To the extend that medication treats root causes of psychiatric illnesses it does so in a very blunt way; wasn't there just a HN comment to the effect of 'People like to say things like "seratonin is the drug that makes you happy," or "oxytocin is the drug that makes you feel love," or "dopamine is the brain's reward mechanism," but those statements are simplified to the point of being wrong.' [1]. Our regular treatments for injuries like burns, acute organ failure like pancreatitis, or physical trauma like car accidents is to treat the symptoms until the body has time to heal itself.
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.
The first step to good treatment is acurate diagnosis. It stands to reason to group by symptoms could support diagnosis as a roadmap. It narrows down what needs to be considered and it ensures relevant possibilities are not overlooked.
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.
I thought all medicine used differential diagnosis, where you start with symptoms and gradually eliminate potential causes, until you're left with the most likely cause.
I do agree. I stand with SSC's criticisms about the details, but I do believe that despite its flaws, it does communicate a very important message effectively.
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.
The other side of the coin that this book helped me to see is that I am not my symptoms.
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.
Interesting bit burried in section IV that I'm posting here in the likely event that most people don't read that far.
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.]
Yes I found this very amusing. For several reasons:
- 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.
> 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?
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.
On a minor pedantic note, its more like the amygdala keeps the score. There is no difference between physical abuse and emotional abuse when it comes to the final end result on the brain.
That's .. the unsolved research question under discussion? As to whether there is a score at all, where it is kept, and how it might be affected? And while is seems there is some evidence, we're still in the middle of the replication crisis?
According to Dr. Sapolsky (Why Zebras Don't Get Ulcers, Behave), there's ample evidence of enlarged, hyperactive amygdalas in chronically stressed individuals, both on artificially stressed lab rats and when looking at differences in individual human beings.
>> The standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, cocurring about once in every million women.
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.
This sounds like more confirmation that the old standard textbooks about psychiatry contained far more traditional belief and sexual pseudoscience than the profession was willing to admit. Remember how long it took to get homosexuality removed from the DSM?
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.
The practice of psychiatry is filled with disasters, and has been more of a reflection of our culture than a science for much of its history. It is good of you to point out how there's been steady improvement-- we should remember that the field's utility can be improved.
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.
> Even the studies that have passed the test of time look a little weird. The Adverse Childhood Experiences study found that obesity and other seemingly nonpsychiatric diseases were linked to child abuse, and recent studies confirm this – but the controls for socioeconomic status are always insufficient, and there’s surprisingly little shared environmental component.
Perhaps whiteness is irrelevant, perhaps not. Socioeconomic background was controlled for the fact that the participants were from the middle class. Whether that's inherent to the US population due to the fact that it's a big part of it, or not is irrelevant. Unless I've missed your point?
> Like so many things, PTSD feels self-evident once you know about it.
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.
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.
A common misperception about ptsd is that it results from discrete traumatic events or episodes. It doesn't in general. More often it results from discrete or continuous traumatic events or episodes together with one or more of alienation, lack of social support, or ostracization. That is one reason why not everyone who experiences a shared traumatic event will develop PTSD.
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
1. PTSD is in actuality frequently triggered by a single, discrete, traumatic event.
2. The feelings of ostracization/alienation and general disengagement from social discourse are indeed well known markers -- except, they follow, rather than lead the onset of PTSD. In other words, they manifest as a result of PTSD -- not the other way around.
While what you're saying is correct, you're describing CPTSD (complex post traumatic stress disorder) rather than PTSD, which typically results from a single traumatic event.
> Because that would seem to be extremely maladaptive for almost all of the last few millenia.
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.
No one is making arguments for optimality of society! If your argument is that societies which traded off mental health of their members (almost certainly an individual fitness hit) for other benefits that allowed them to outcompete individuals in other societies to overcompensate that fitness hit (similar to farmers beating hunter gatherers), I'd be curious to hear what these psychologically more idyllic less successful societies far less prone to PTSD would have looked like.
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.
On the other hand you could look at this the other way round: catastrophic physical illness was widespread, why not catastrophic mental illness? And if you look at history with the right lens, you can find examples that might support this. There are huge areas of folk psychology around things like "demonic possession" that are usually attributed to what would today be understood as forms of mental illness.
Just because someone is surviving and even reproducing doesn't mean they're not psychologically damaged. Even to quite a considerable extent.
Your analogy does not work. The reason people succumbed to widespread and severe physical illness, despite clear evolutionary pressure not to do so, is because there is equal evolutionary pressure on pathogens to successfully bypass host adaptations.
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.
The same reasoning, from the same prior, suggests that lead poisoning probably also doesn't exist. After all, the Romans made water pipes out of the stuff, and look how well they did.
Roman water pipes ended up covered in (substance I don't recall the name of), and so not much lead leeched into the water. Water jugs made of lead were probably more of a problem.
The same holds true for modern lead pipes. They work fine, until they don't.
> 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.
He does indeed make the very same point and his review suggest he thinks of the author as more or less a proudly scientifically illiterate witch doctor whose patients' behavior bears not resemblance to that of his own patients.
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.
> Local official records indicate genital retraction endemics in Hainan Island and Leizhou Peninsula in Guangdong, China, as early as the late 19th century.
Intuitively it would seem like PTSD is a result of a traumatic break in expectations, rather than the trauma itself. Now, here's my reasoning for this.
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?
The brain processes and integrates emotional/instinctive responses, not abstract concepts -- even in situations where said responses are themselves caused by abstract triggers (e.g. stock market crash and subsequent loss of wealth/job/etc.).
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?
There's no such "time scale", it all depends on the strength of the selection. Lactase persistence went from zero to ~100% in some populations in less than 3000 years.
Sure – I'm just taking issue with the "in retrospect obvious". PTSD might still be real, or it might turn out to be in fact several different phenonema, with possible some more real than others. But there is a lot that's counter-intuitive.
Readit News
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.
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.
[1] https://news.ycombinator.com/item?id=21519901
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.
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.
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.
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'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.
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...
Deleted Comment
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.
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.
The same holds true for modern lead pipes. They work fine, until they don't.
> 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."
https://www.voa.org/understanding-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?
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.