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Things Probably Matter

A while back when I wrote about how China’s economic development might not have increased happiness there much, Scott Sumner wrote a really interesting response, Does Anything Matter?

He points out that it’s too easy to make this about exotic far-off Chinese. Much the same phenomenon occurs closer to home:

If nothing really matters in China, if even overcoming horrible problems doesn’t make the Chinese better off, then what’s the use of favoring or opposing any public policy? After all, America also shows no rise in average happiness since the 1950s, despite:

1. A big rise in real wages.
2. Environmental clean-up (including lead–does Flint matter?)
3. Civil rights for African Americans
4. Feminism, gay rights.
5. Dentists now use Novocain (My childhood cavities were filled without it)
6. 1000 channels in glorious widescreen HDTV
7. Blogs

I could go on and on. And yet, if the surveys are to be believed, we are no happier than before. And I think it’s very possible that we are in fact no happier than before, that there’s a sort of law of the conservation of happiness. As I walk down the street, grown-ups don’t seem any happier than the grown-ups I recall as a kid. Does that mean that all of those wonderful societal achievements since 1950 were absolutely worthless?

But there are exceptions. I recall reading that surveys showed a rise in European happiness in the decades after WWII, and Scott reports that happiness is currently very low in Iraq and Syria. So that suggests that current conditions do matter.

The following hypothesis will sound really ad hoc, but matches the way a lot of people I know talk about their lives. Suppose people’s happiness is normally calibrated around the sort of lifestyle that they view as “normal.” As America got richer after 1950, it all seemed very normal, so people didn’t report more happiness. Ditto for China during the boom years. Everyone around you was also doing better, so you started thinking about how you were doing relative to your neighbors. But Germans walking through the rubble of Berlin in 1948, or Syrians doing so today in Aleppo, do see their plight as abnormal. They remember a time before the war. So they report less happiness than during normal times.

The obvious retort is – modern Chinese grew up when China was very poor. Why didn’t they calibrate themselves to poverty, such that sudden wealth seems good? What’s the difference between a Chinese person going from poverty to wealth, versus a Syrian going from stability to chaos? Might it be a shorter time course? A sudden shock is noticeable, a gradual thirty-year improvement in living standards isn’t?

Probably not. There seem to be a lot of cases where happiness of large groups does change gradually in response to social trends less dramatic than a world war.

First, consider African-Americans. The New York Times calls the increase in black happiness over the past forty years “one of the most dramatic gains in the happiness data that you’ll see”. This is not just about poverty; in 1970, blacks who earned more than 75% of whites were only in the tenth percentile of white happiness. Today, those blacks would be in the fiftieth percentile; they’re still doing worse than would be expected based on income, but not nearly as much worse. This is a very sensible and predictable thing to find. Black people face a lot less racism and discrimination today than in 1970 [citation needed], so assuming that was really unpleasant we shouldn’t be surprised that they’re happier. But notice that this is a time course very similar to the rise of China! It doesn’t look like black people picked a happiness level to calibrate on and then never bothered to adjust. It looks like they adjusted exactly like we would expect them to, even over the course of a multi-decade change.

Second, consider women. In 1970, US women were generally happier than US men. Today, the reverse is true. There seems to be a general pattern around the world of women being happier than men in traditional societies and less happy than men in modern societies (though see Language Log for a contrary perspective). I don’t think of this as a weird paradox. It seems perfectly reasonable to me that having to work outside the home makes people less happy, getting to spend time with their family makes them more happy, and having to work outside the home but also being expected to take care of your family at the same time makes them least happy of all. In any case, the point is that the numbers are changing. Men and women aren’t just fixating on some level of happiness and staying there, they’re altering their happiness level based on real trends, just like African-Americans did (but apparently unlike Chinese).

Third, I was finally able to find a paper that had really good data on change in happiness in different countries, and it supports the idea that happiness can change significantly on a countrywide level.

This is change in happiness in a bunch of countries between about 1990 and 2010 (the years were slightly different in each country). There are other graphs for related concepts like life satisfaction and subjective well-being that look about the same.

The most striking finding is that most countries got happier between those two years – sometimes a lot happier. In Mexico, the percent of people saying they were very happy increased by 25 percentage points!

Just eyeballing the graph, there’s not an obvious relationship between happiness and economic growth – China is still near the bottom like we talked about before, and France – a country that’s been First World since forever – is near the top. Even Japan, which is famous for its decades of stagnation, has done pretty well. But the authors tell us that after doing their statistical analyses, there is a strong relationship with economic growth. Okay, I guess.

They also say there’s a dramatic relationship with freedom and democracy. Mexico, the top country on the graph, went from a relatively closed to a relatively democratic government during this time. South Africa, number five, went from apartheid to no apartheid. Some of the ex-Communist countries like Poland and Ukraine also look pretty good here. On the other hand, other ex-Communist countries like Lithuania and Estonia are near the bottom. I wonder if this has to do with cutoff points – since every country started at a slightly different time, maybe they began sampling Poland during the worst parts of Soviet dictatorship and got Lithuania right in the first euphoria of independence? I don’t know. It all seems very noisy.

They also mention that the United States’ supposedly level happiness is kind of a misunderstanding. People say things like “Happiness in the US has been flat from 1950 to today”, but in fact it declined from 1950 to 1979 and increased from 1980 to today. They attribute this to the 1950s being unusually happy; then the 60s and 70s being unusually conflict-prone, and the Reagan Revolution and Clinton years were back to being optimistic. They don’t have data that stretches too long after that.

(This is pretty neat for Reagan and Clinton. When I die, I’ll consider my life a success if people attribute a spike on national happiness graphs to my influence.)

So apparently population happiness levels do change in response to relevant social changes, even on multi-decade timescales. Which brings us back to asking – what’s up with China?

The graph above shows India as doing okay – not great, but okay. But a similar graph on subjective well-being – which should be another way of looking at the same thing – shows India as doing pretty poorly, right down there with China – even though its GDP per capita quadrupled during the period of study.

I see a lot of conflicting perspectives about whether economic growth increases national happiness. It may, but the effect isn’t as big as you’d expect, and is usually overpowered by other factors. Maybe it isn’t even direct, but has something to do with development increasing democracy, liberalism, rule of law, and stability. China got the development, but its happiness genuinely didn’t increase because of country-specific factors that have something to do with how it developed (inequality? pollution? authoritarianism?).

This matches the race and gender data. Blacks saw a big happiness boost during a time when their feeling of freedom (but not their income) increased relative to whites. Women saw a small happiness drop during a time when their income (but not their feeling of freedom) increased relative to men.

So it looks like happiness can change. It just didn’t change in China over the past thirty years. The apparent paradox of improving economic situation and stable/decreasing happiness is genuinely paradoxical. Intangibles are probably just way more important than money, even amounts of money big enough to raise whole countries out of poverty.

Pushing And Pulling Goals

This is a distinction I’ve always found helpful.

A pulling goal is when you want to achieve something, so you come up with a plan and a structure. For example, you want to cure cancer, so you become a biologist and set up a lab and do cancer research. Or you want to get rich, so you go to business school and send out your resume.

A pushing goal is when you have a plan and a structure, and you’re trying to figure out what to do with it. For example, you’re studying biology in college, your professor says you need to do a research project to graduate, and so you start looking for research to do. You already know the plan – you’re going to get books, maybe use a lab, do biology-ish things, and end up with a finished report which is twenty pages double-spaced. All you need to figure out is what you’re going to select as the nominal point of the activity. There’s something perversely backwards about this – most people would expect that the point of a research project is to research some topic in particular. But from your perspective the actual subject you’re researching is almost beside the point. The point is to have a twenty page double-spaced report on something.

School and business are obvious ways to end up with pushing goals, but not every pushing goal is about satisfying somebody else’s requirements. I remember in college some friends set up an Atheist Club. There was a Christian Club, and a Buddhist Club, so why shouldn’t the atheists get a club too? So they wrote the charter, they set a meeting time, and then we realized none of us knew what exactly the Atheist Club was supposed to do. The Christian Club prayed and did Bible study; the Buddhist club meditated, the atheist club…sat around and tried to brainstorm Atheist Club activities. Occasionally we came up with some, like watching movies relevant to atheism, or having speakers come in and talk about how creationism was really bad. But we weren’t doing this because we really wanted to watch movies relevant to atheism, or because we were interested in what speakers had to say about creationism. We were doing this because we’d started an Atheist Club and now we had to come up with a purpose for it.

Sometimes on Reddit’s /r/writing I see people asking “How do you come up with ideas for things to write about?” and I feel a sort of horror. So you want to write a novel, but…you don’t have anything to write about? And you just sit there thinking “Maybe it should be about romance…no, war…no, the ennui of the working classes…or maybe hobbits.” I can understand this in theory – you want to be A Writer – but it still weirds me out.

You may have noticed I don’t really like pushing goals. Part of it is an irrational intuition that they’re dishonest in some way that’s hard to explain. It usually ends up with me trying to figure out what to do my biology research project on, and I think “well, I can’t think of anything I really want to research, so maybe I should just do whatever is easiest”. But if I do whatever is easiest, I feel really bad, and worry maybe I have some kind of obligation to research something important that I care about. So I get my brain tangled up trying to figure out how much easiness I can get away with, then feeling bad for asking the question, then trying to come up with something important I honestly want to do, which doesn’t exist since I wasn’t doing a biology research project the month before my professor assigned it to me and so clearly I am only doing it to satisfy the requirement.

Another part of it is that it’s often a sign something has gone wrong somewhere. In the example of the Atheist Club, that thing might have been starting the club in the first place. But assuming that we genuinely want to start the club, then the presence of a pushing goal means we don’t understand why we wanted to start the club. If we wanted to start it because we wanted to hang out with other atheists, then that offers a blueprint for a solution to the problem – instead of planning all these movies and speakers, we should just hang out. If we did it because we thought it was important for atheism to be more visible on campus, then again, that offers a blueprint for a solution – spend our sessions trying to improve atheism’s campus visibility. If we just sit there saying “I guess we have an Atheist Club now, better think of something to do at meetings”, then it seems like something important hasn’t been fully examined.

The third part of it is that things done for push goals usually suck. Maybe this isn’t a human universal – my go-to example is Edgar Allen Poe deciding to write a creepy poem and coming up with The Raven from first principles – but it’s true for me. If I have to write a report on a topic I don’t care about, then even if I’m really trying to do a good job, it’s not going to be as good as something I actually want to write about. Sometimes I try to solve this by making lists of things I want to pull, then using them when the appropriate pushing situation comes up. For example, when I knew I would be assigned research projects and writing assignments on a regular basis, whenever I thought of something I wanted to research or write, I wrote it down, then consulted the list when I needed it. I have a similar list of interesting things to work into stories. This is one reason I’m not interested in journalism – I worry that if I have to produce specific articles on specific things within a time frame, they’ll probably suck.

OT54: Threadical Doctor

This is the bi-weekly visible open thread. There are hidden threads every few days here. Post about anything you want, ask random questions, whatever. Also:

1. Sorry for the low volume of blogging lately. My promotion to fourth-year resident has left me with less time and I’ve yet to find a way around that.

2. Thanks to everyone who donated to the Help Multiheaded Get Out Of Russia fund a couple of months ago. I’m happy to report that Multiheaded did in fact get out of Russia and is now in a European country. She can say more if she wants.

3. Latest person who needs help: Alison is originally from the Caribbean but has been in the US San Francisco Bay Area for a few months. She’s having immigration issues and for some reason being able to stay in the United Kingdom for a little while would help. If you are in the United Kingdom and willing to host somebody who many people in the rationalist community can vouch for being not an axe murderer, read more here.

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3/4

Related: 1/4, 2/4

[Content warning: psychiatry, suicide. Note that all stories involving patients are mixtures of several different people which have been obfuscated and changed around in order to protect confidentiality. The ethical standard I have heard in this situation is “must be so well disguised that the patient would not recognize himself if he read it” and I have tried to meet that standard – which means that these capture the spirit of situations only. The same is true of some of the other stories here, just in case. Please do not link.]

I.

I’m back at Our Lady Of An Undisclosed Location hospital now as a final-year resident. You wouldn’t think a year would make so much difference, but it does.

Identifying residents by their year is easy. The first-years walk around, deer-in-the-headlights look to them, impossible to confuse with anybody except maybe a patient having a panic attack. The middle-year residents are a little more confident. And then the final year residents, leading teams, putting out fires, taking attendings’ abuse in stride.

(True story – last week an attending yelled at me for not knowing some minor detail about uraemic encephalopathy. Later I couldn’t find the detail he’d mentioned, so I asked for a reference, and he said it had been discovered by one of his friends at the big university hospital where he used to work, but the friend had died before he could publish his findings. I think the attending realized as he was talking that it might have been unreasonable to expect me to know a fact whose discoverer took it to the grave with him, but he didn’t apologize.)

It’s only sort of a facade. 99% of things that happen in a hospital are the same things that happened yesterday and the day before, so if you hang around long enough you can learn what to do, or at least which consultant you can call to make it not your problem anymore. On the other hand, Actual Pathology is still a gigantic mystery. I’m not sure this ever changes. One in every X patients with symptoms won’t have any of the things that could possibly be causing those symptoms, won’t respond to any of the treatments that are supposed to cure those symptoms, and you’ll still have family members and hospital administrators demanding that you fix it right now (and in psychiatry, X is probably a single digit number). All you can do is keep up the facade, put your skill at taking attendings’ abuse in stride to good use, and start learning necromancy so you can summon the one big university hospital researcher who studied it but never got a chance to publish their findings.

II.

Two of the most important things I learned during my third year were “Tell me more” and “[awkward silence]”.

“Tell me more,” works for every situation. Part of the problem with psychotherapy is that you’re always expected to have something to say. As a last resort, that thing is “Tell me more”. It sounds like you’re interested. It sounds like you care. And if you’re very lucky, maybe the patient will actually tell you something more, as opposed to their usual plan to stonewall you and hide all possibly useful information.

I saw something on Tumblr the other day which, despite being about a 9-1-1 operator, perfectly sums up being a doctor too:

my bf has many interesting stories and observations from his new job as a 911 operator

my favorite is how meandering people are, even in the midst of a terrible emergency

they respond to “what is the emergency” with “well, the thing is, four weeks ago–”

and then he’s like “WHAT IS THE EMERGENCY RIGHT NOW”

and they’re like “so what happened this morning was, i said to my wife, i said–”

“WHAT IS CURRENTLY HAPPENING AT THIS MOMENT”

“oh i’m having a heart attack”

And:

my second favorite is how specific he has to get sometimes

like, “what is your emergency?”

“i’m sitting in a pool of blood.”

“… is it… your blood?”

“yes i think so”

“do you know where it’s coming from?”

“probably the stab wound”

“have you been stabbed?”

“oh yah definitely”

Psychiatry is like this, except it’s all very vague, and your patients are really suggestable, and people are always afraid that if you just ask specific questions like “Are you depressed?” then they’ll say yes to make you happy and won’t talk about how the real problem is their anxiety or something. So instead, the patient says something like “I’m sitting in a pool of blood”, and I say “Tell me more…”. They say “Well, it’s my blood.” I say “Tell me more…”. After repeating this process a couple of times, we finally get to the stabbing, and the patient doesn’t feel like I railroaded over their chance to tell their story.

Or it helps you figure out what’s important to the patient. If someone said “I hate my husband so much,” my natural instinct might be to ask “Why?”. But maybe why isn’t the question the patient cares about. Maybe what she really wants to talk about is how guilty she feels about hating their husband, and if I asked her why then we’d get on a tangent about what the husband is doing that never addresses her real problem. Maybe she’s agonizing every moment about whether or not to divorce him, and losing sleep over it, and coming to me for a sleeping pill. Maybe she’s just hatched a plan to kill him and wants to check it over with me to see if I can find any flaws. In any case I should probably figure out why they hate him eventually, but if their real issue is whether or not I approve of their murder plot then we should probably get to that first.

So instead, it’s “I hate my husband so much.” “Tell me more.”

“I’m feeling depressed.” “Tell me more.”

“Sometimes I think life isn’t worth living.” “Tell me more.”

“Listen, if you don’t give me a prescription for Adderall right now I swear to God that I will stab you right here in this office!” “Tell me more.”

This has seeped into my personal life. I was on a date with a girl earlier this year, and whenever she started telling me about her life I would just say “Tell me more”, and it worked.

And then there’s [awkward silence]. I learned this one from the psychoanalysts. Nobody likes an awkward silence. If a patient tells you something, and you are awkwardly silent, then the patient will rush to fill the awkward silence with whatever they can think of, which will probably be whatever they were holding back the first time they started talking. You won’t believe how well this one works until you try it. Just stay silent long enough, and the other person will tell you everything. It’s better than waterboarding.

The only problem is when two psychiatrists meet. One of my attendings tried to [awkward silence] me at the same time I was trying to [awkward silence] him, and we ended up just staring at each other for five minutes until finally I broke down laughing.

“I see you find something funny,” he said. “Tell me more.”

III.

If the patients are cryptic, the doctors are even worse. In a worst case scenario, I’ll be filling in for another doctor – this happens all the time at free clinics, but it happens at least a little wherever there are doctors who go on vacation. The documentation will be obscure or missing. The patient’s family is out of contact range. My only information will be the patient in front of me, whose information-transmitting ability is on par with that person from the Tumblr post who took four tries to mention that they’d been stabbed.

So imagine this – a guy from out of state moves in, comes to me without any documentation, and says in a monotone that his only problem is feeling “weird”. All my “tell me mores” and [awkward silences] fail to get him to explain further. I look at his medication list, and he is on a cocktail of supramaximal doses of really old-school antipsychotics that I could not imagine giving anybody unless they were an axe murderer who had killed their last three psychiatrists and I wanted to cool their metaphorical brain temperature to the level of winter on Pluto. Sure enough, the guy is stiff, displays no emotions, and his only hobby is staring at the wall – all exactly what you would expect of somebody who is super-drugged on all of the strongest chemicals known to mankind. I ask him if maybe he’s schizophrenic, or bipolar, or something. He says no, he just feels “weird”.

I know that if I don’t change the medication, he will probably be a zombie like this until such time as somebody else does change it, which may be never. But if I do change the medication…well, there must be some reason somebody put him on that, and the idea of somebody who needed that much medication not being on it is too horrible to imagine. Also, I’m only seeing him once, and then he gets transferred to someone else. What do I do?

The maxim is “do what lets you sleep at night”, so I punted. I kept him on his medications and turned him over to the next guy. I just hope the next guy gets my documentation instead of thinking “Dr. Alexander kept him on all this medication…I wonder what he knows that I don’t.”

IV.

“Instead of putting patients on these toxic medications, why don’t you just give them therapy?”

Sometimes I worry I might be the worst person in the world to do psychotherapy. My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works. I know this is exactly the opposite of what psychotherapy is supposed to teach, and all I can say is that it works for me and I seem to be pretty psychologically healthy and maybe I am just a mutant.

My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible, and maybe this is why my only really serious relationship only lasted a year or two, but it leaves me with something of an understanding deficit for the people who want to replay every single argument they’ve ever had with their spouse and figure out exactly what it means about their mental state.

Heck, even polyamory is like this. I can’t tell you how many patients I’ve had come in because their partner is cheating on them, or they worry their partner is cheating on them, or they’re cheating on their partner, or their partner worries they’re cheating on them, or something, and my natural instinct is to just say “Have you considered not worrying about it?” and as usual my natural instinct is terrible. So instead I just say “Tell me more…” and listen to them describe how the possibility of their girlfriend cheating is rending their heart in two.

This is even worse in any form of therapy based around investigating childhood traumas. Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption? But of course I can’t say that. I just have to play along. And then somebody expects me to come up with something to heal the maternal trauma that I’m not even sure people really have, and then if I do come up with something it feels like a clever fake.

Cognitive behavioral therapy is a little better, because it tends to be pretty common sense techniques that any reasonable person would agree with. The problem is, it’s pretty common sense techniques that any reasonable person would agree with. I think that I and most of my friends would respond to the average CBT session with a sort of anger at being condescended at, combined with annoyance at the therapist for wasting our time with obvious things. “My job sucks”. “Well, have you considered making a list of good and bad things about your job?” “Yes, that was the process by which I determined it sucks. How much am I paying you again?”

Most of the time I do therapy, I feel cringeworthy, unnatural. I feel like a fraud, even when (according to the supervisors watching me) I’m doing it exactly right. I feel like I’m responding to people in fake, silly ways, like they’re coming to me with problems from the depth of their being and I’m giving them facile non-answers. It doesn’t even help that most of them get better anyway. In a way, that just makes it worse. How dare you get better after me telling you stupid things I feel embarrassed to say? That’s just going to encourage people to make me keep doing that!

V.

I nevertheless hold a special place of annoyance in my heart for psychoanalysis/psychodynamic therapy.

The attending who trains me in psychodynamic therapy is an elderly doctor in a very ritzy office by the water full of creepy modern art statues. He is convinced that patients’ lives revolve around their therapy and their therapists. I know that in moderation this is the idea of “transference”, a genuine and important tenet of the therapy style. My attending does not do it in moderation.

My patient will say something like “My best friend moved away and now I am sad”, I will think “That sounds straightforward, better bring it up to my attending and see how he wants me to deal with this.” My attending will invariably say “What your patient means is that he’s afraid of losing you, his therapist.”

I will say “No, I’m pretty sure he actually lost his best friend. He told me all about how they’d been together since middle school, but now he moved away to take a job in Texas, and then he broke down crying.”

Then my attending will get really angry and tell me that if I’m just going to take everything my patient tells me exactly literally, then I shouldn’t be in psychiatry, because a monkey could listen to a patient say he was sad about losing his best friend and conclude he was sad about losing his best friend, and my duty as a trained professional is to be able to see beneath that to the true thought which my patient is trying to express. Which is always, 100% of the time, about how much the patient cares about psychodynamic therapy and wants to continue doing it.

Even worse, he wants me to do this to the patient. When the patient says “I’m really upset about losing my best friend”, I’m supposed to answer “Are you sure this isn’t about how you’re worried I’m sort of like a friend to you and one day you’ll lose me?” If talking about relationships and cognitive therapy makes me cringe, this super quadruple makes me cringe.

Still, I have to do it, because my attending grades me and if I don’t pass psychodynamic therapy I don’t get to graduate. So I do it, and then my attending declares he was right all along based on extremely strained interpretations of whatever happens next. Like, if the patient misses their next appointment, he’ll say “I see your patient missed their next appointment. That means they’re having a defensive reaction to the fact that you called them out on their being afraid of you leaving them. And to think that you told me you weren’t sure that was true! This just shows how much you still have to learn about psychodynamics. I certainly hope that after this you won’t keep questioning me every time I try to help you.”

It occurred to me leaving his ritzy office that pretty much every philosophical idea I have – rationalism, belief in science, libertarianism, atheism, anti-SJ – originate in this feeling of revulsion at other people ordering me to believe things that I think are wrong and me not being allowed to argue with them. But I held my tongue. I told my patient what he told me to tell him, and I accepted my attending’s increasingly bizarre declarations that he had linked all of my patients’ future actions to the success of his proposed interventions.

But when I leave for good, I’m getting him a present, and it’s going to be a copy of The Nurture Assumption. Heck, maybe I’ll give that to all the psychoanalysts I know.

VI.

It’s kind of morbid to feel smug about your patients not attempting suicide, but I guess I am a kind of morbid person.

The doctor down the hall from me had one of his patients attempt suicide in October. Then another doctor I knew had two of his patients attempt suicide in the same week in January. And I was really sympathetic and tried to comfort them, but I also had a part of my mind thinking “Hey, I haven’t had any of my patients attempt suicide yet, this is pretty good.”

March. April. May. My coworkers told me their stories, but I kept my secret morbid goal – I was going to go the entire year without any of my patients trying to kill themselves. I mean, on one hand this sounds like a pretty minimal standard. On the other, when you’re taking care of like a hundred mentally ill people, many of whom have really bad depression and a history of past suicide attempts, it’s not exactly trivial.

I got the call just a few weeks ago. The patient was a former heroin addict who had been clean for a long time. He slipped, took heroin, felt terrible, and stabbed himself in the heart.

Luckily the heart is a little to the right of where most people think it is. Stabbing yourself in the lung isn’t great either, but he was a young healthy man and he could take it. He went to the hospital, they patched it up a little, and he was fine. He said it was the best thing that had ever happened to him and now he knew how low he could get and he was going to stay clean forever and today was the first day of the rest of his life.

A lot of things in psychiatry are reverse lotteries. In the regular lottery, you pay a constant small cost for the possibility of a stupendous benefit. In the reverse lottery, you get a constant small benefit at the risk of a stupendous cost. Lots of things are like this. If you give someone a powerful medication, then they’ll definitely recover, but there’s a risk you’ll have a catastrophic side effect. If you let a severely ill patient leave your office when they promise they’re okay, then you definitely save them the trauma of an involuntary hospitalization, but there’s a risk they’ll do something disastrous. If you don’t check someone’s vitals every time you see them then it definitely makes the appointment quicker and smoother, but there’s a risk you’ll miss something really bad.

It’s really easy to fall into playing reverse lotteries. I think almost everybody does it to a degree. The usual pattern is to play some of them tentatively, do more and more of them as you reap the benefits and nothing goes wrong, then boom, close call, and you resolve never to do anything like that again and you’re going to do a full half-hour neurological examination on everybody who comes into your office including random passers-by who just want to use the bathroom.

After my patient stabbed himself I spent a week totally neurotic, looking over every aspect of his case – could I have checked up on his Narcotics Anonymous meeting attendance more frequently? Maybe if I’d given him a long lecture every appointment about how heroin was definitely still bad, that would have changed something? Maybe if I hadn’t forgotten to check his blood pressure that one time…? In the end, I decided I had done a pretty okay job on that case – which just made me more acutely aware of all of the reverse lotteries I was playing on everybody else. Now I’m a little bit paranoid. Maybe that’s temporary. Maybe it’s permanent. I don’t know. The DSM-V says you have to have it six months before you can give yourself a schizophrenia diagnosis, so there’s that.

I am getting good at dealing with annoying attendings, meandering patients, unreasonable requests, and silly bureaucracy. Actual Pathology remains scary, mysterious, and really hard to predict. Hopefully that’s what fourth year is for.

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Links 7/16: Peter Linklage

Newspapers showed the picture of a man who died in the terrorist attacks on Paris last year. But somebody who is clearly the same man was shown as being killed in the Orlando nightclub shooting last month. And now the same person is in the body count for the attacks on Ataturk Airport in Istanbul. Who is the mysterious man who dies in every terrorist attack?

Systematic review: “Overall, results of these studies do not indicate a higher prevalence of eating disorders among fashion models compared to non-models.”

/r/AccidentalRenaissance: everyday photos which, when you think about it, look kind of like Renaissance paintings.

Pseudoerasmus reviews Empire of Cotton. Even though he’s not a fan of the book, just his hostile summary helped me understand some of what people mean when they say that “free trade” has set back the developing world.

In order to counteract my (and maybe your) usual bias: here’s somebody fired for doing a study that found that some people were racist.

Oh God oh God oh God functional brain imaging studies are awful – “If the whole-brain across-subject correlation analysis with 16 subjects considers 1000 possible correlations (considerably less than the number of voxels in a whole-brain analysis) the peak correlation coefficient is expected to be about 0.75, even if the true correlation is actually 0.” Best read alongside the old study that replicated various results about the brain in a dead salmon to show how easy it was to fake.

Supposedly most antidepressants don’t work in kids and teens, but Prozac does. But I find anything that discovers striking cross-SSRI differences a little hard to believe.

Psssst, wanna buy a slightly used Soviet surplus tank? What if I told you they cost less than a nice car?

The Kentucky meat shower was an unexplained event when meat fell from the sky like rain. “A letter from Dr. Allan McLane Hamilton appearing in the publication Medical Record [stated] that the meat had been identified as lung tissue from either a horse or a human infant, ‘the structure of the organ in these two cases being almost identical.'” Well that’s not creepy at all.

LWer and Future of Humanity Institute scholar Stuart Armstrong is in the news for a paper written together with Google AI scientists detailing an exciting new avenue for working on AI safety based on designing intelligences that will not resist their own shutdown. Related: scientists at Google, OpenAI, Stanford, and Berkeley publish a review of Concrete Problems In AI Safety.

China plans to evict 5000 monks from Larung Gar Buddhist Monastery for political reasons. If you’re wondering what kind of monastery has 5000 monks, take a look at the photos.

Related: Treasure-hunting is big part of Tibetan Buddhism, and monks inspired by mystical revelation will often go out and unearth treasures or manuscripts hidden by past saints.

Review: “Nominal agreement between initial studies and meta-analyses regarding the presence of a significant effect was not better than chance in psychiatry, whereas it was somewhat better in neurology and somatic diseases.” If I’m understanding this right, it means that an initial study about something in psychiatry conveys literally zero evidence about whether that thing is true or not.

China plans to cut meat consumption by 50%.

Everyone knows that “millennials” are far left, but the truth is more complicated – really into gays, marijuana, and immigration, but not much different than older generations on support for the poor or on racial issues (wait, really?)

Snopes: despite media reports, there is no evidence that the Orlando nightclub shooter was gay. This is so confusing to me that I worry it’s some kind of prank, but how could I even check?

David Chapman on Brexit. This probably has something to offend everybody.

A list of 308 online effective altruism-related resources. Some of the Facebook groups seem kind of Potemkin-y, though.

Relevant to my interests: there was once an unrecognized US state called Scott.

Economists are very pessimistic about (one version of) universal basic income.

Related: an alternative to universal basic income is the universal basic share, where the government says something like “We pledge to forever redistribute 10% of GDP, whatever that may be, among our citizens as a universal basic income”. The hope is that even if this starts out as not enough, as the economy grows it will gradually become more and more until it’s enough for people to live on. But I worry that ignores the effect discussed here, where if the government had tried that in 1900 then by now the income would have grown to the amount the poor needed to support themselves in 1900, yet would still be way below the amount what we consider a minimum standard of living today.

Company that handles tech company interviews makes a feature that changes what gender an interviewee’s voice sounds like, to see if women get more tech jobs when the company thinks that they’re men. To the surprise of nobody who is paying attention, there is no anti-woman bias found and in fact women do slightly better when they are known to be female.

If you miss the predictions of health risks and so on that you used to be able to get from 23andMe, you can get them free from Genotation now – just upload your 23andMe data to their site and it will do the calculations for you. I’m slightly confused that its ancestry panel seems to think I’m East African, but I guess in a sort of cosmic long-term sense it’s not wrong.

Wait List Zero is a group that encourages altruistic kidney donation, eg donation to a person you may not know who really needs a kidney.

Two new studies conclusively determine that the apparent “obesity paradox” – the finding that sometimes overweight people had lower death rates than normal weight people – was an error and that in fact being normal weight is healthier.

Last week: Kentucky legalizes hair braiding without a license. This week: fiery storms scour the land; the living envy the dead.

A few months ago I argued that open-source AI would be a bad thing because it would sabotage safety efforts. Now Nick Bostrom investigates the same question much more rigorously.

D.R. Hagen on why the 11th, the 2nd, and the 3rd of each month are mentioned in books less often than other days.

Psychiatrists often use drugs that modulate norepinephrine, like Effexor and Strattera, on the assumption that this chemical plays an important role in psychiatric disease. But some people have a rare disease that causes them to have literally no norepinephrine at all yet seem to be psychiatrically normal. I have no idea how this can be true.

Intermittent fasting is no better than just dieting the normal way. I hate to gloat, but this concludes an almost ten-year argument I’ve been having with an acquaintance who said that the failure of doctors to immediately endorse intermittent fasting proves that the medical profession are all quacks who don’t care about their patients.

Ross Douthat: The Myth Of Cosmopolitanism. “[We give] the elite side of the debate (the side that does most of the describing) too much credit for being truly cosmopolitan. Genuine cosmopolitanism is a rare thing. It requires comfort with real difference, with forms of life that are truly exotic relative to one’s own….The people who consider themselves “cosmopolitan” in today’s West, by contrast, are part of a meritocratic order that transforms difference into similarity, by plucking the best and brightest from everywhere and homogenizing them into the peculiar species that we call “global citizens”…There is more genuine cosmopolitanism in Rudyard Kipling and T. E. Lawrence and Richard Francis Burton than in a hundred Davos sessions.”

The campaign for rigor in UFO hunting.

Tell me I’m misunderstanding this, or else it’s the most confusing thing I’ve read all month: study shows that sugar only makes you gain weight insofar as it tastes good, and mice who have been genetically engineered not to like the taste of sugar fail to gain much weight on sugar even when they eat exactly as much of it as the mice who like it. Possible implications for artificial sweeteners?

Refugee children who arrive to the US at a very early age like 6 months don’t have substantially better outcomes than those who arrive at a later age like 6 years. This is very strange, because we expect them to be living in a terrible deprived environment before immigration but a much better one afterwards. How do we reconcile this with the “childhood stresses of poverty” theory of poor people’s problems like in that study about the Cherokee reservation?

Also, how do we reconcile behavioral genetics with attachment theory?

All of those studies showing that a picture of eyes watching you would make you behave in a more prosocial way are the latest victims of the replication crisis.

The first fully automated fast food restaurant comes to San Francisco.

Brian Tomasik has a really good article on gains from trade that asks the important question – why is there ever conflict? Why don’t people just Aumann-agree on how the conflict would probably go, and skip the part where they actually waste all of their resources fighting each other? See also this SSC post.

Great moments in Donald Trump tweeting.

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OT53: Pel-open-esian War

This is the bi-weekly visible open thread. There are hidden threads every few days here. Post about anything you want, ask random questions, whatever. Also:

1. Thanks to Arvin (arvinja on Reddit) for creating the ad randomizer I was looking for. The ads on the side of the blog should now appear in a random order every time you load the page.

2. Comments of the week are in reponse to the book on chronic pain. George Dawson MD DFAPA talks about his experience as a psychiatrist treating the condition; Arnold Layne talks about his experience as a radiologist; Bram Cohen talks about his experience with massage and ergononomics; and Steve B and Matt H talk about their experience as patients. A lot of people say they’ve had good success with Dr. Sarno’s course which is very similar to the book I reviewed.

3. Thanks to everyone who emailed me saying they were willing to try the pain book as an experiment. If you didn’t say that you needed me to buy you the book, I’m assuming you’re buying it yourself. If you did say that you needed me to buy you the book, I’ve either responded with a request for more information (in the first three cases), or said that I’m going to limit this to three people to save on my own budget (in the next few cases). If you want the book, can’t afford it, and weren’t one of the first three people, it looks like John Sarno’s very similar book The Mind-Body Prescription is less than $1 on Amazon. Once again, I can’t actually recommend any of these.

4. This will probably go on the next links post, but it’s neat enough to deserve mention here too: Emil Kierkegaard has made an app type thing that demonstrates the problems with comparing discordant groups that I mentioned here.

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Survey Results: Suffering Vs. Oblivion

[Content warning: suffering, oblivion]

Every so often, someone on Reddit realizes that about half of people wipe themselves with toilet paper sitting down, and the other half do it standing up. This discovery is followed by horror on both sides that other people do it differently.

I occasionally have the same feeling when I talk about ethics. Every so often I run up against a base-level clash of intuitions with somebody else, where they disagree on a preference I would have expected to be self-evident. This is pretty bad, since some forms of consequentialism are a lot more elegant if we imagine that all apparent moral disagreements are just people failing to think through their own preferences clearly enough and everyone really agrees about morality deep down.

A lot of these clashes of intuitions have to do with the idea of suffering versus oblivion. In order to explore this further, I asked people on Twitter and Tumblr to answer some survey questions like the following:

1. Would you rather:

Option A: Live the rest of your life working 16 hour days, seven days a week, as a McDonalds cashier. You will have no time off except the time you need to eat, sleep, and use the restroom. Your entire life will be spent doing McDonalds cashier related tasks. When you are no longer able to perform your tasks, you will die painlessly.

Option B: Die painlessly right now.

2. Would you rather:

Option A: Live a long but unhappy life. You live to be 120. You spend most of your time unhappy, but you are not actively suicidal.

Option B: Live a short but happy life. You die ten years from now, in 2026, after being hit by a car. Until then, you do fulfilling work, have happy relationships, and meet with success in most projects.

3. Would you prefer:

Option A: A world with 100 trillion trillion sentient beings, all of whom are miserable, but not quite so miserable that they wish they were never born.

Option B: A world with 1 million sentient beings, all of whom are happy and consider their world a utopia.

4. What percent certainty of going to Heaven would you need before you would prefer a world with both Heaven and Hell to a world where death ends inevitably in oblivion?

Before checking the results, I had five hypotheses.

First, people would be split in their answers to these questions, with strong feelings on both sides.

Second, answers to all questions would correlate along a general factor of oblivion-preference versus suffering-preference. That is, people who would prefer oblivion to working at McDonalds would also be more likely to prefer a short life of happiness to a long life of unhappiness, et cetera.

Third, this factor would predict whether somebody endorsed a form of population ethics which promotes creating new people (question 3 is sort of just asking this already, but I also included a more direct question along those lines).

Fourth, this factor would predict some real-world consequences like whether people believed in a right to euthanasia and whether they were signed up for cryonics.

Fifth, happier people would be more likely to prefer suffering over oblivion, because they view life as generally excellent and so oblivion represents more of a sacrifice for them.

1090 people took the survey (social media is a wonderful thing). The survey specifically asked that you not think about other people or the question’s effects on them and just choose whatever made you selfishly happier. Several people complained to me that the concept of “generally unhappy, but does not wish they were never born” didn’t make sense to them, which I guess is data in and of itself. The results were:

The first hypothesis was confirmed:

On the fourth question, people answered everything, from demands of certain salvation (n = 320), to being okay with certain damnation (n = 69), and everything in between.

The second hypothesis was weakly confirmed:

Orange results are significant at p < 0.05, red results at p < 0.01. We did not adjust for multiple comparisons.

There are significant correlations between most of the questions, but they are not very strong. When I limited the analysis to the people who felt most strongly about their answers to the questions, the correlations went up a bit:

The third hypothesis was not supported.

I asked people a pretty direct question about the ethics of creating new people:

5. Creating new sentient beings is:

Option A: Exactly comparable to improving the lives of existing beings. Creating a life that experiences 100 utils is exactly as good as improving existing lives 100 utils.

Option B: Generally good, but less good than improving the lives of existing beings by the same amount

Option C: Morally neutral

Option D: Bad

Option E: I am not a consequentialist or otherwise don’t want to answer this question

The results were:

The only correlation with any other question was with the one hundred trillion trillion sentients question, which is basically asking the same thing in different words. The correlation with all the other questions was not significant and in fact very close to zero.

The fourth and fifth hypotheses were weakly supported.

I gathered a general score of people’s pro-oblivion or pro-suffering bias based on their answers to the first three questions and how strongly they felt about them. It predicted the following:

The specific questions here were:

Whether you believe everybody has a right to commit suicide if they want, including people who are not terminally ill.

Whether you believe people who are terminally ill should have a right to suicide, ie traditional euthanasia.

Whether you are interested in signing up for cryonics.

And whether you consider yourself a happy person.

All were correlated with preference for oblivion over suffering in the expected direction, but not very strongly.

So it looks like people have very different opinions about when to choose death versus suffering, but that these opinions are inconsistent and only weakly driven by broad cross-situation intuitions.

You can see the survey here, but please don’t take it since I’m done getting data. You can download anonymized results here (.xlsx, .csv)

I Wrote A Blog Post, But Did Not Adjust For The Fact That The Title Would Be Too L

I recently got in some fights with psychoanalysts on the importance of parenting. They mentioned that one good test for genuine parent effects – as opposed to genetic effects, stress-related effects, toxin-related effects, et cetera – would be things that seemed to depend more on one parent than the other. In particular, in order to rule out intrauterine factors, we should be looking at effects that depend disproportionately on the father. For example, if young women with distant fathers are uniquely more likely to become lesbians, that would be a pretty convincing demonstration of the importance of parenting.

So I was interested to see a recent study that claimed a good father/son relationship – but not a good mother/son relationship – had a special role in sons’ development. University of Guelph, Parents, Especially Fathers, Play A Key Role In Young Adults’ Health:

The researchers found that young adults who grew up in stable families with quality parental relationships were more likely to have healthy diet, activity and sleep behaviours, and were less likely to be obese.

Surprisingly, they found that when it came to predicting whether a young male will become overweight or obese, the mother-son relationship mattered far less than the relationship between father and son.

“Much of the research examining the influence of parents has typically examined only the mother’s influence or has combined information across parents,” said Prof. Jess Haines, Family Relations and Applied Nutrition, and lead author of the paper.

“Our results underscore the importance of examining the influence fathers have on their children and to develop strategies to help fathers support the development of healthy behaviours among their children.”

Okay. Let’s look at the study. It’s a correlational study of 6000 kids age 14-24. They were asked to rate the quality of their relationship with each parent, then they were tested for various unhealthy behaviors: obesity, eating disorders, fast food intake, soda intake, TV watching, sedentariness, and poor sleep.

Among all participants, better relationships led to less disordered eating, increased physical activity, and better sleep. This was true both for child/mother relationship, child/father relationship, and child/generic-measure-of-family-functioning relationship. So far this isn’t surprising. There was no attempt to control for wealth, class, or anything else, let alone genes. And a lot of these children are still living with their parents, so good parenting is going to be important to them right now (the study didn’t separate children who were still with their parents from adult children who weren’t). No surprise to find an effect here.

Among no participants did better relationships affect soda consumption or screen time, whether it was the child/mother relationship, the child/father relationship, or the child/generic-measure-of-family-functioning relationship. Okay. I guess these are somewhat more neutral things that good parenting doesn’t affect much.

Among female but not male participants, better relationships decrease fast food consumption. This was true both for child/mother relationships, child/father relationships, and child/generic-measure-of-family-functioning relationships (I believe all marriages should be between a man, a woman, and a generic-measure-of-family-functioning). This suggests that maybe parents care more about their daughters eating fast food than their sons – or maybe those daughters themselves care more. In either case, this wouldn’t be too surprising.

What about the blockbuster result that fathers, but not mothers, affect male children’s obesity level?

The odds ratio for obesity with a good mother-son relationship was 1.04, confidence level (0.85, 1.27).

The odds ratio for obesity with a good father-son relationship was 0.80, confidence level (0.66, 0.98).

Okay. You are measuring seven different outcomes on two different genders of child. On thirteen of these tests, results are concordant between fathers and mothers. On one of them, results are discordant, in that with mothers the confidence interval included 1.00, but with fathers the confidence interval merely included 0.98.

You could either conclude that fathers have a unique ability to affect their sons’ (but not their daughters’) level of obesity (but not disordered eating, or fast food eating, or soda drinking, etc). Or you could conclude that if you do enough tests, 5% of the time something will fall just outside a 95% confidence interval.

Let’s see what the study’s Limitations section has to say about this:

We calculated 42 tests and did not adjust for multiple comparisons.

Why would you do this? If NASA preceded their missions with statements like “We are launching a rocket to Jupiter, but we did not adjust for the fact that it is very far away,” we would stop taking them seriously. But for some reason in the social sciences it’s okay?

All right, fine, let’s hear your excuse:

Of these tests, 25 were statistically significant at the 0.05 level, much larger than the 2 we would expect by chance.

This might work for individual results, but it doesn’t work for discordances between results, which is what they’re trying to show.

Suppose I want to prove that a certain medicine only works on people whose names begin with the letter M (and suppose in reality, the drug works on everybody). My experiment has 80% power to detect the drug effect when it works. I do fifty tests on fifty different populations – elderly Latino women, young black men, genderqueer Caucasian neonates, Thai rice farmers, unemployed auto workers, whatever – and divide each of them into a subgroup with M-names and a subgroup with other names. I’m actually simulating this right now in an Excel spreadsheet, and here are my results:

Among non-M-names, 42 of the populations test positive, which is much as expected – the drug works and we have 80% power to show that it does, so we should expect 50*0.8 = 40 positive results on average. A little random noise brings that to 42.

Among M-names, 43 of the populations test positive, which is also close to 40. So here everything is just as we would expect.

But! In six of the populations, the drug works “differently” for people with M-names and other names. For example, on Test 18 (let’s call this Thai rice farmers), the drug works for rice farmers who have names beginning with M, but doesn’t work for rice farmers who have names beginning with other letters.

So I report this in the literature as “Astounding! Drug works for Thai rice farmers with names beginning with M, but not for Thai rice farmers with names beginning with other letters!” Some annoying person comes back with “but you did a bunch of comparisons and didn’t correct for that”. And I retort “Aha! But actually 85 of my 100 tests came back positive, compared to only 5 that would be expected by pure chance, so clearly there’s something there! There’s an M-name effect after all!”

This is comparing apples to oranges. Yes, you’ve shown that your drug works. But you haven’t come close to showing that it works differently for people whose name begins with M. Your evidence doesn’t even suggest that it does.

But this is what this paper is doing when it says it has evidence that male obesity is affected by the father and not the mother, and claims it doesn’t need to adjust for multiple comparisons.

As Exhibit B, I present the graphs:

I think this is noise.

The paper itself mentions the father-son difference in one paragraph in the Discussion section, but doesn’t even find it worthy of mention in the Conclusion. It’s the press release that plays this up into the major finding of the study. Why?

Because the press release came out three days before Father’s Day.

Look:

In time for Father’s Day, a new University of Guelph study has found that parents, and especially fathers, play a vital role in developing healthy behaviours in young adults and helping to prevent obesity in their children.

I think overly cutesy university PR departments do a lot more damage than is generally realized.

On the other hand, one impressive thing about this paper is its willingness to cite large quantities of stuff. For example, a quote:

Level of bonding or closeness with a parent has also been shown to moderate the association between maternal-BMI and daughter-BMI [17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60] and parental and adolescent weight-related behaviors [17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61].

I am not going to go through 43 studies to see if any of them are any good, but I guess if there are 43 studies claiming these sorts of parental effects I should be a little more humble.

So: does anyone know of any good studies showing gender-specific-parent effects on a child that don’t seem obviously related to intrauterine or Y-chromosomal factors?

Book Review: Unlearn Your Pain

[Content warning: discussion of chronic pain and related conditions, and the debate over whether some of them may be psychological in origin. None of this is medical advice or a recommendation to start or stop any form of therapy. Low confidence in my conclusions here.]

I.

Some of the most interesting lectures in medical training are the ones that start with “Okay, you’re all going to think I’m a quack, but…”

This was how Dr. Howard Schubiner started the lecture he gave at the hospital where I work. Dr. Schubiner isn’t an obvious quack – he’s a professor of medicine at the local university, directs a clinic at a reputable hospital nearby, and is on the editorial boards of a bunch of medical journals. And although his lecture raised what we will generously call a few red flags, there was also just enough interesting stuff there that I couldn’t resist buying his book Unlearn Your Pain to learn more.

Dr. Schubiner’s specialty is psychosomatic complaints – bodily symptoms that don’t come from any obvious disease and seem to reflect psychological stress. Everyone agrees that this category exists. Most doctors have stories about conversion disorder – usually patients who become “paralyzed” in previously healthy limbs after some life crisis. One of my medical school professors had a pretty good diagnostic test for this – feign a punch at the patient’s face, really quickly, without warning her. If she instinctively uses her “paralyzed” limb to block it, it’s conversion disorder. The same sort of thing works for pseudoseizures – apparent seizures not associated with objective seizure EEG activity. There’s a legend about a neurologist telling a medical student that a certain patient’s fit was a pseudoseizure, and the patient interrupting his seizure to protest “No it isn’t!”.

Most people who have worked with conversion or pseudoseizure patients don’t doubt their inherent honesty. These patients aren’t faking, per se. Such a person genuinely can’t move their limb, can’t just decide not to have seizures. Often they’re very distressed at what’s happening to them (although sometimes they really aren’t). Psychologists like to say that it’s subconscious – whatever that means. Just like somebody crippled by panic attacks, the symptoms are real and involuntary, but they’re also psychologically produced.

The existence of this category isn’t controversial, but its size definitely is. Some people propose a long list of conditions – fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, chronic Lyme disease, tension headaches, interstitial cystitis, et cetera – that they think of as mostly or entirely psychosomatic. On the other hand, patients’ rights groups get very upset at claims that their conditions are “all in their head”, accuse doctors of thinking that they’re lazy or making up their symptoms, and pass around stories with titles like RE: RE: RE: FWD: RE: THE MEDICAL PROFESSION about some guy whose doctor dismissed him as making up his symptoms but who was later diagnosed with zebra-itis and cured with an experimental gene therapy treatment.

Dr. Schubiner is a psychosomatic complaint maximalist. He thinks that just about anything that can’t be traced to a well-understood physiological cause is probably psychosomatic – in his language, Mind-Body Syndrome or MBS. He quotes a fascinating theory by Edward Shorter that this all dates back to the invention of the tendon hammer, ie that little thing doctors hit your knee with:

An important advance in medicine was the discovery of deep tendon reflexes. The simple test of striking a tendon with a reflex hammer can quickly distinguish pathological from psychological paralysis. Amazingly, once doctors could do this test, the number of people with this type of conversion disorder decreased substantially, and now the condition is rare. When doctors and the general public come to view a medical condition as psychologically induced, it is less likely to occur..the subconscious mind is unlikely to produce symptoms that will be easily seen as psychological. But since humans continue to experience great stresses and strong emotions, paralysis has been replaced by chronic back pain, fibromyalgia, fatigue, irritable bowel syndrome, and many other symptoms.

When Schubiner talks about fibromyalgia and fatigue, he’s not so far outside (one edge of) respectable medical opinion. But he goes further and lists migraine headaches, heartburn, carpal tunnel syndrome, tinnitis, postural orthostatic tachycardia, repetitive stress injury, and reflex sympathetic dystrophy as likely Mind-Body Syndrome as well. And most explosively, he says the condition explains almost all pain.

Schubiner admits there is such a thing as anatomically-caused non-psychological pain. It tends to be associated with very obvious injuries like dropping an anvil on your foot, and it tends to go away after a couple of weeks at most. Anything more mysterious and chronic – facial pain, TMJ pain, joint pain, abdominal pain, neck pain, shoulder pain, tendonitis, and especially back pain – is probably Mind-Body Syndrome. After a medical workup has failed to reveal obvious cancer or infection, these are almost certainly psychosomatic and continuing to treat them as potentially medical just makes them worse:

When patients with Mind-Body Syndrome are labeled as having degenerative disc disease on the basis of an MRI….symptoms can be exacerbated and patients harmed by medical diagnoses. This occurs because the diagnosis creates fear and the belief that there is something seriously wrong with one’s body. These emotions activate the anterior cingulate cortex, which creates even more pain by ramping up the learned nerve pathways of MBS.

If this were true, it would be really important. Surveys suggest that between 40 million and 100 million Americans have chronic pain; the former study finds 67% of them say their pain is “constantly present” and 50% say it is sometimes “unbearable and excruciating”. The financial cost is between $60 billion and $600 billion per year. I’m not sure what to think about all these estimates that differ by orders of magnitude, but the point is that there’s a “chronic pain epidemic” and it’s really bad. The mainstay of treatment for chronic pain is opioids, and by non-coincidence there’s also an opioid addiction epidemic and an opioid-related death epidemic. To some degree the government can use regulation to trade off pain burden against opiate deaths, but no point at that curve is very palatable and we desperately need some kind of real solution.

Schubiner says he has it. It’s time to admit that all of this pain that’s getting all epidemicky is almost entirely psychosomatic. It might start with a real injury, but after that injury heals the brain “remembers” the relevant pain pathways and exploits them as a way to express psychological stress. He presents some fascinating and delightful evidence for this.

A guy named Harold Schraeder studied prevelance of chronic whiplash in Lithuania, of all things. He found the prevalence was zero. In most Western nations, a certain subset of people who get in car accidents suffer chronic disabling neck pain, presumably related to having their neck get suddenly jerked by the force of the impact. But Schrader found that this never happened in Lithuania, even though they had a lot of accidents and their cars were no safer than ours. Simotas and Shen found that there was zero whiplash in demolition derby drivers, even though they got into crashes all the time and it was basically their job description. Further studies found that accident victims with more neck injury were no more likely to develop whiplash than victims with less neck injury. Perhaps, they argue, chronic whiplash isn’t a bodily injury at all, but a culture-bound syndrome in which people who expect whiplash to exist use its symptom profile as a way of expressing their psychological tension.

Then there’s back pain, one of the most common and disabling types of chronic pain – Medicare back-pain related costs have grown about 3-4x in a decade. Standard medical workup for back pain usually involves getting an x-ray or MRI, finding some problem with the discs in the spine, and treating with painkillers, steroids, or surgery. Schubiner is not convinced. He notes studies that find that radiographic findings of disc degeneration or herniation do not accurately predict future back pain. Yes, most back pain sufferers will have problems visible on MRI, but most perfectly healthy people pulled off the street will also have problems visible on MRI – for example, this study finds that half of all 21-year-olds in Finland have a degenerated disc, and a quarter have a bulging disc. The book quotes an NEJM article as saying that “neither baseline MRIs nor followup MRIs are useful predictors of low back pain”. However, studies (1, 2) find that a patient’s job satisfaction does predict their future back pain. Books and studies called things like Time To Back Off?, Back In Control and Watch Your Back point out that many surgeries and injections for back pain work no better than placebos in controlled experiments, with a review article in the Journal of the American Board of Family Medicine concluding that “prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain” On the other hand, Schofferman et al found that childhood trauma correlates heavily with success of back pain treatment: 95% of patients with a happy childhood got better after back surgery, but only 15% of patients with multiple childhood traumas did.

Based on these studies and others like them, Schubiner concludes that chronic back pain is psychological rather than physiological. He thinks there may have been some original minor injury, of the sort that most people would get over in a couple of weeks. This causes the nerves to “sensitize” – ie the brain is primed to think about and remember this form of pain. Then, when people recall their subconscious tension over childhood trauma and the stresses of life, they express it as back pain through the sensitive nerve pathways.

Extend this model to headaches, irritable bowel, chronic fatigue, and everything else, and you have Dr. Schubiner’s theory of pain.

II.

If all of this pain has a psychological cause, then it should have a psychological solution. But psychological solutions to chronic pain are no more effective than physical ones. For example, Cochrane Review finds that cognitive behavioral therapy for chronic back pain has a moderate short-term effect which fades quickly. There was a similar effect for neck pain which Cochrane found “could not be considered clinically meaningful” and which also faded quickly.

Dr. Schubiner says this is because cognitive behavioral therapy is inappropriate for this condition. It’s caused not by negative thoughts and dysfunctional behaviors, but by unresolved childhood traumas. He recommends a therapy designed to help resolve such traumas called Intensive Short Term Dynamic Psychotherapy.

Freudian therapy (“psychoanalysis”) usually takes several years to get anywhere, and may take ten years or longer to complete. Around the 1960s, some psychiatrists got tired of waiting and invented a high-speed version called “psychodynamic therapy”. Schubiner’s version, which derives from the word of a guy named Dr. Davanloo in Montreal, promises results in as little as four weeks. It involves a lot of stuff, including some kind of silly-sounding things like writing affirmations, finding your acupuncture points, and putting your body in very masculine “power poses” and raising your fists and shouting “I AM GOING TO OVERCOME MY PAIN!”. Dr. Schubiner demonstrated this last in front of us and he did indeed look very masculine and determined; if I were chronic back pain, I would definitely put him on my list of people to avoid.

But the heart of the therapy is a technique for returning to traumatic childhood moments. You try to figure out what your traumatic childhood moments were – for example, maybe your father got drunk and beat you up. So you go back to the incident, either as a solo visualization or in a conversation with a partner. It goes something like this:

Doctor: Tell me what’s happening

Patient: I’m in my childhood home. My father approaches me, beer bottle in hand, looking really angry.

Doctor: How do you feel?

Patient: Really scared.

Doctor: But also?

Patient: Angry.

Doctor: Good! You have every right to! Tell your father that!

Patient: Father, I’m really scared and angry!

Doctor: Now what does your father do?

Patient: He doesn’t care.

Doctor: And what would you like to do now?

Patient: Beat up my father.

Doctor: Then go back into that experience and beat up your father.

Patient: AAAARGH! I HATE YOU SO MUCH, FATHER! YOU RUINED MY CHILDHOOD! GRAAAAAAAAAH! DIE! DIE! DIE! DIE! DIE!

Doctor: How do you feel now?

Patient: My chronic back pain is gone!

There are enough variations on this to make it a four week course, but in Schubiner’s examples (which he takes from real clinical practice), even something as simple as this can be enough to make chronic pain go away near-instantly. He has about a dozen anecdotes from his own practice where this happens. Then the rest of the course is just solidifying that gain and making sure it doesn’t come back.

I talked to a professor of psychoanalysis I work with about this. She says that Davanloo is well within the psychoanalytic mainstream. She says that she herself is not a big fan of his work, because she thinks it’s important to spend those several years unpeeling a patient’s defenses instead of just smashing them with a sledgehammer. But she says chronic pain patients may have unusually strong defenses and that maybe the sledgehammer approach is the right one. So overall she cautiously approves.

On the other hand, my more cynical readers might note that “well within the psychoanalytic mainstream” isn’t exactly equivalent to “definitely not a quack”. Schubiner is aware of this and has tried to get some evidence for his method. Along with a case series, he has published a study on the psychological treatment for fibromyalgia, in which 45% of the intervention group experienced significant pain relief compared to 0% of the controls. He also tested the full version of his therapy in a preliminary trial in which “two-thirds of the patients improved at least 30% in pain”.

So, should we believe him?

III.

I tried to verify some of the claims in this book and discovered things were much more ambiguous than it let on.

The idea of whiplash as psychosocial is still controversial in the literature. It’s true that some studies in Lithuania and Greece show almost no whiplash. But some critics say that these studies lacked enough power to find a difference in whiplash rates among countries even if such a difference existed. There were also extremely weird fluctuations in the data – for example, the same team in the same city doing two studies a few years apart found neck injury rates of 15% versus 47%. Here’s a long and acrimonious debate in a medical journal about this. But interestingly, even the pro-psychosocial side doesn’t seem to want to say there’s no biological component. And such a claim would be difficult to sustain given studies that show significant effects of things like head position during an accident on future whiplash rates. You can find a good summary of some of the points on each side here. Here’s another review by Dr. Arthur Croft, Ph.D., D.C., M.Sc., M.P.H., F.A.C.O., and Emmy award nominee (really) – who says, brutally:

Ferrari, et al., have recently promoted the so-called biopsychosocial model in the context of whiplash, making numerous excursions into the literature in support of it. The lynchpin of their theory relies on two studies conducted in Lithuania which purportedly followed the natural history of late (i.e., chronic) whiplash in a population of persons exposed to rear-impact motor vehicle crashes – the putative injury mechanism for acute whiplash injury. Unfortunately, “fatal” errors in study design in both cases prevented meaningful interpretation of their results, not the least of which was that only a small portion of their cohort actually had an acute whiplash – the necessary precursor for late whiplash. Our post hoc power calculation revealed that their cohort was inadequate to support any of their conclusions.

Unfortunately, many authors – since these flaws were pointed out – have failed to be dissuaded from citing this literature in support of the biopsychosocial theory, particularly those authors from the camp of the nonbelievers. These Lithuanian papers, it should also be noted, stand alone as outliers to more than 50 other published reports of outcome over the past 45 or so years, and arrive at some rather improbable conclusions that almost immediately beg some questions. In the first paper, the results suggested that persons exposed to whiplash mechanisms would have about the same long-term neck pain as age-matched uninjured persons in the population. In the second study, acute whiplash trauma exposure seemed to actually have a protective effect, somehow immunizing these people against future neck pain. Again, these findings would be particularly interesting if the studies had the added virtue of being valid on a statistical and methodological basis.

To these I would add that even if a US-Lithuania whiplash rate difference existed, it wouldn’t necessarily have to be psychological. Some people bring up Americans having bigger cars; other people bring up differences between American and European car seat headrest design, and still others bring up differences in US and Lithuanian diets and lifestyles which might affect pain and healing.

The book’s treatment of back pain also raises some concerns. It is definitely true that the relationship between back pain and radiographic findings is way lower than anybody wants to admit, and that MRI isn’t very useful for diagnosis. That having been said, the relationship is not zero. For example, in this study, patients with the highest level of radiographic degeneration were 4.5x more likely to be in the highest back pain category compared to patients with the lowest level of radiographic degeneration. The correlation is not one, but neither is it zero. Some people with lots of back pain will have no radiographic findings, and some people with lots of radiographic findings will have no back pain, and the relationship is weak enough that using MRIs for diagnosis is heavily discouraged, but in general the two have a positive and significant relationship. See for example here, here, and here. I don’t know to what degree this affects the book’s thesis, but it seemed important to point out.

Nor is there any more clarity about the relationship of back pain to job (dis-) satisfaction. I was able to find three meta-analyses on it. One of these, Linton, said that:

The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor.

But Hartvingsen et al concluded:

According to recent epidemiological literature we found moderate evidence for no positive association between perception of work, organisational aspects of work, and social support at work and LBP. We found insufficient evidence for an association between stress at work and LBP. Regarding consequences of LBP, there was insufficient evidence for an association between perception of work in relation to consequences of LBP. There was strong evidence for no association between organisational aspects of work and moderate evidence for no association between social support at work and stress at work and consequences of LBP. There were major methodological problems in the majority of studies included in this review and the diversity in methods was considerable. Therefore associations reported may be spurious and should be interpreted with caution.

Finally, Hoogendoorn, Poppel and Bongers, who sound like a band for very young children, are very ambivalent. They do find some effects, but they all give off an air of desperation, eg “Low job control was found to have a statistically significant positive effect on short and long absences due to back pain, except in men in lower grade jobs and women in higher grade jobs, in whom the effect was reversed”. They are very open about this, and conclude:

“Evidence was found for the effect of some of the psychosocial work characteristics, but there is no psychosocial work characteristic for which evidence was found in all reviews…the conclusions drawn in the various reviews appear to be rather heterogenous”.

And, very significantly for our purposes:

“Having evaluated the strength of the evidence for both physical and psychosocial factors as risk factors for back pain, using the same methods, the question arises of whether the findings indicated a difference in the evidence for physical and psychosocial factors. Strong or moderate evidence has been found for heavy physical work, lifting, bending, and twisting, and whole body vibration at work. Unlike the results for psychosocial factors, these results were rather insensitive to slight changes in the assessment of the findings and the methodologic quality of the studies and in agreement with the results of previous reviews on physical load. This indicates that the body of evidence supporting the role of these physical load factors as risk factors for back pain is somewhat more consistent than that for the psychosocial factors)

The consensus in pain medicine is that pain depends on both psychological and physical factors working together. Schubiner is trying to shift that consensus to say pain is almost entirely psychological and based mainly on childhood trauma. But the studies, while not ruling out a psychological cause, are very emphatic that physical causes definitely matter. And even the papers supporting psychological causes say that, among all such causes, there is unusually little evidence for childhood abuse as a factor.

But the part that bothered me most was the use of Schofferman’s study showing that childhood trauma predicted back surgery success rate (I should note that he doesn’t cite this explicitly in the book, but he implicitly works off it, and he discussed it explicitly during the lecture). This was a surprising study that cried out for replication – and which was in fact re-tested in 2002 on a larger sample by Nickel, Egle, and Hardt. They were unable to replicate the findings. Chronic back pain patients, surgery-failing and otherwise, were no more likely to have childhood trauma than anybody else. This bothered me because Schubiner played up Schofferman’s 1991 study that supported his hypothesis without even mentioning this one. People have a right to present their case the way they want, but when someone clearly ignores better and more recent evidence, it makes me a little more skeptical of everything they say.

IV.

What about the psychiatric part of Unlearn Your Pain‘s program?

The psychodynamic therapy literature is even more of a mess than the back pain literature. I’ve been there before and don’t want to go back. You can read Jonathan Shedler and Jared DeFife in support and James Coyne and Michael Anestis in opposition. I find myself more sympathetic to the “doesn’t work very well” camp, but the field is muddy enough, and my biases against it strong enough, that I place little confidence in that judgment.

So let me try to cut through all of this with my favorite weapon for these kinds of things: behavioral genetics. Of the five behavioral genetics studies on back pain I could find, four (1, 2, 3, 4) found no shared environmental effect on back pain, with only one dissenter. This is in common with a large literature finding little shared environmental effect on a host of psychological problems including depression, anxiety, and bipolar disorder – and indeed, it would be very strange if chronic pain were more related to childhood experiences than those were.

Psychiatry tried really hard to give the “childhood trauma causes everything” thesis a go for fifty-something years. Sure enough, psychiatrists found loads of childhood trauma, because, much as pretty much everybody will have something weird with the discs in their backs that can be detected on MRI, pretty much everybody will have something weird with their childhood that can be detected with psychotherapy. Using the kabbalistic method, you can always find suspicious coincidences linking their childhood trauma with their current pain. Schubiner writes – as far as I can tell, 100% seriously – that:

When someone develops a pain in the buttocks, there may be someone in their lives who is ‘a pain in the butt’.” Someone who develops difficulty swallowing may be reacting to a situation in life that is ‘hard to swallow’. I evaluated a woman with pain in the bottom of her feet. While waiting in line one day, she realized there was a situation in her life that she ‘just couldn’t stand anymore’

I want you to appreciate how much willpower I’m showing here. There is form of psychiatry based around corny puns, and yet instead of emailing these people my resume immediately I’m trying to maintain a cautious skepticism.

And when I do, I just can’t believe it. The early psychoanalysts weren’t doing science, they were taking Sofer’s Law and running with it. Eventually we realized that talking about childhood traumas wasn’t predictive, wasn’t especially curative as per rigorous studies, and we moved on.

There’s a lot of controversy around this decision, but I think behavioral genetics has made the childhood-trauma side increasingly untenable. Assuming twin studies aren’t entirely fatally flawed – something thousands of people have looked for and nobody has found – childhood shared environment, which presumably includes things like abusive parents, just doesn’t affect adult outcomes very much. I can’t see a way to reconcile that with psychoanalytic theories and I don’t think we should keep trying.

I don’t deny that there are a lot of suspicious coincidences. But I think if we look harder, we can find that those suspicious coincidences all have more reasonable explanations. Like, yes, people with a lot of psychological problems tend to have a lot of back pain. But again, when you do twin studies:

On initial analysis considering the participants as individuals, rather than twins — and therefore not accounting for genetic and familial factors — the odds of having back pain were about 1.6 higher for those with symptoms of depression and anxiety.

On further analysis of monozygotic twins — who are genetically identical — the association between symptoms of depression and low back pain disappeared. This suggested that the strong association found in non-identical twins resulted from the “confounding” effects of common genetic factors influencing both conditions. For example, genes affecting levels of neurotransmitters such as serotonin and norepinephrine might affect the risk of both conditions.

Previous studies have shown a “consistent relationship” between back pain and depression — a combination that may complicate diagnosis and treatment. However, the nature of the association remains unclear. The new study is the first to examine the relationship between depression and low back pain using twin data to control for genetic and familial factors.

When you control for genetics, WHICH YOU SHOULD ALWAYS DO AND I AM SO SERIOUS ABOUT THIS, this explains the entire psychological problem/back pain link. Combined with the previous twin studies showing no effect of childhood environment, this is a very strong challenge that theories claiming a psychogenic origin of back pain based in life events will have trouble surviving.

V.

So in the end, what do we make of chronic pain?

Many, many, many people report using the techniques in Unlearn Your Pain (or the closely related techniques of Dr. John Sarno) and having good success. I don’t think this is entirely coincidence or bias. But I’m also not willing to entirely buy into this repressed childhood trauma theory.

There are definitely some types of pain which are not related to bodily injury. My best evidence for this, which Dr. Schubiner talks about too, is the people who have pain which is anatomically implausible or “migrating”. By “anatomically implausible” I mean pain that cuts willy-nilly across the body’s neural regions; pain in the distribution of the ulnar nerve may be an ulnar nerve problem, but if it has half the distribution of the ulnar nerve plus half the distribution of the median nerve, while leaving the other half of both distributions pain-free, it’s a little harder to figure out what could be causing it (especially if it’s on both sides equally!) By “migrating”, I mean that somebody has right hand pain, the doctor gives them some kind of treatment, that goes away, the next day they have right foot pain, another treatment, it goes away again, and the next day they have diarrhea. While there are very rare processes that can do something like that, when it goes on long enough that’s good evidence that the pain isn’t anatomical.

But I think the way in which pain isn’t anatomical is more complicated than the simple model that Unlearn Your Pain uses. Instead of the brain “using” pain to express repressed emotions, maybe gating and modulating pain sensations is just really hard.

Let me give an example [trigger warning for inducing mild bodily discomfort]. Right now, you’re suddenly aware of the feeling of your tongue in your mouth. And right now, the top of your head is suddenly really itchy. Also, right now something is wrong with your saliva and you’re swallowing consciously, but it feels awkward and you’re worried something might be wrong with your throat.

This isn’t because I have magic powers inflicting these things on you, it’s because you’re constantly receiving all sorts of sensations and your brain effectively gates and modulates them. You’ve always got micro-itches and micro-pains going on everywhere – no part of your body is one hundred percent optimal and even if it were there are still variations in neural noise – but your brain usually correctly decides these aren’t worth your time. It’s only when something forces you to focus on them – whether worry about a back injury, or an annoying blogger – that they make it through.

All psychiatric disorders are heavily comorbid. People with one or more of depression, anxiety, OCD, anorexia, autism, gender dysphoria, PTSD, et cetera are many times more likely to have all of the others, and it doesn’t just seem to be in a boring “OCD is depressing and makes me anxious” sort of way. All of this seems to relate to a general factor of neural messed-up-ness. It wouldn’t be surprising if this correlated with some kind of messed-up-ness in the neural systems that are supposed to process and gate pain.

Remember also that stress can cause relapses of many very biological and serious diseases like ulcerative colitis, multiple sclerosis, or epilepsy. Also, inflammation seems to be a shared and complicated factor between various bodily illnesses, stress, and depression. So for stress to cause a “relapse” of chronic pain, all we’d need is for it to put extra pressure – whether through inflammation or some other method – on an already slightly messed-up pain-gating system in the brain. And then there’s muscular tension, which I inexcusably forgot to mention until now but which is also a relevant system by which stress affects chronic pain.

We know that pain is very sensitive to the placebo effect – I’m generally a placebo effect skeptic, but even arch-skeptics Hróbjartsson and Gøtzsche agree that pain is one of the few places where the placebo effect really dominates. This is why we so often see faith healers and saints and miracle water from Lourdes treating pain so effectively – at least briefly. It’s why homeopathic treatment for pain shows such an amazingly good effect size.

And, I will say cynically, it’s why so many people have reported (genuine) success from Unlearn Your Pain and related programs. It’s why Schubiner writes:

I believe that each and every person with Mind Body Syndrome can get better because it is possible to overcome MBS by using this program. Those people who are unable to accept that their symptoms are due to MBS, or who do not develop positive expectations of relief, or who are unable to believe that they can make changes in their health and in their lives are the people who are less likely to improve.

Part of me wants to say that we have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo”.

Another part worries this is unfair. If the placebo effect comes from the brain’s ability to gate pain, then saying “You’re not really affecting the brain’s ability to gate pain, it’s just the placebo effect” stops making sense. It’s not that it doesn’t work and is just placebo – it’s that it does work, via placebo.

There’s something to be said for glorifying in the placebo effect, laying it on as hard as possible, putting on the fanciest robe and wizard hat you can find and saying “I CAST YOU OUT BY THE POWER OF PLACEBO, GO FORTH AND SIN NO MORE!” I think in some ways there can be better and worse placebo therapies just as there can be better and worse real therapies, placebo therapies that activate the placebo effect only a little and don’t help much, and placebo therapies that activate the placebo effect really strongly and use it to work miracles. Maybe we should give more status to the best placebo therapies, to view them as highly perfected works of the placebomantic arts in the same way that powerful medications are triumphs of psychopharmacology. I think psychodynamic therapy and everything descended from it would have a high place in that pantheon.

In that sense, I think Unlearn Your Pain might be a useful book. I think that even if I accept what I consider the consensus theory of chronic pain – genuine (if small) lingering injuries (or nerve sensitization from such) interacting with a poorly-wired pain gating system in the brain which is highly susceptible to placebo effects – Unlearn Your Pain remains a useful book, as the distilled wisdom of many years of work trying to activate those effects as strongly as possible.

Another possibility is that the active ingredient isn’t the intensive psychotherapy, it’s the belief that the pain is caused by Mind-Body Syndrome. It seems just possible that this belief could break the cognitive loops that seem so relevant in all of these processes.

So I guess I’m in a weird spot in terms of what I think of Unlearn Your Pain.

I think it’s definitely right that a lot of pain has psychosomatic components. I think it probably helps treat psychosomatic pain, maybe really effectively, and partly for the reasons that it thinks it does.

But I’m not convinced by its more sweeping claims that physical injuries play little-to-no role in chronic pain. Along with Schubiner’s talk of nerve sensitization, one can imagine a scenario in which alternatively apparently-healed physical injuries may leave very small irritations on local nerves, and that the degree of irritation a nerve is able to bear without giving you chronic pain is related to your general neural-non-messed-upness and stress level. In such a scenario psychological factors might play a role in gating the pain, or in tensing or releasing muscles around the pain, but would not entirely explain it.

I’m also not convinced by its claims that childhood trauma has any interesting relationship with pain, nor that trauma-related therapy has a unique non-placebo ability to deal with such pain. I think that childhood trauma is overemphasized throughout psychiatry and that this theory of pain represents a step in the wrong direction. If trauma-related therapy works, it works by a nonspecific process of making people feel like they’re doing something useful and taking their attribution for their pain off of bodily processes.

Niels Bohr used to hang a horseshoe above the door to his office, saying “I’m not superstitious, but I hear this works whether you believe in it or not.” Part of me is tempted to recommend Unlearn Your Pain to my patients on the same principle. And if any readers of this blog have chronic pain and want to try to the month-long self-help therapy course in this book, I would be very interested in hearing back from you (please tell me before you start, so that there aren’t response biases). If the $25 price of this book is the difference between someone in that category trying vs. not trying it, I’m happy to send you the book if you agree to get back to me with your results. Contact me at slatestarcodex@gmail.com if you’re interested in this.

Links 6/15: URLing Toward Freedom

Did you know England has one of the highest rates of tornadoes per unit area of anywhere in the world?

Why do some schools produce a disproportionate share of math competition winners? May not just be student characteristics.

My post The Control Group Is Out Of Control, as well as some of the Less Wrong posts that inspired it, has gotten cited in a recent preprint article, A Skeptical Eye On Psi, on what psi can teach us about the replication crisis. One of the authors is someone I previously yelled at, so I like to think all of that yelling is having a positive effect.

The Prescription Drug vs. Tolkien Elf Quiz. I am a doctor and Silmarillion fan, and I still only got 93%.

A study from Sweden (it’s always Sweden) does really good work examining the effect of education on IQ. It takes an increase in mandatory Swedish schooling length which was rolled out randomly at different times in different districts, and finds that the districts where people got more schooling have higher IQ; in particular, an extra year of education increases permanent IQ by 0.75 points. I was previously ambivalent about this, but this is a really strong study and I guess I have to endorse it now (though it’s hard to say how g-loaded it is or how linear it is). Also of note; the extra schooling permanently harmed emotional control ability by 0.5 points on a scale identical to IQ (mean 100, SD 15). This is of course the opposite of past studies suggest that education does not improve IQ but does help non-cognitive factors. But this study was an extra year tacked on to the end of education, whereas earlier ones have been measuring extra education tacked on to the beginning, or just making the whole educational process more efficient. Still weird, but again, this is a good experiment (EDIT: This might not be on g)

Did you know: Russian author Sergey Lukyanenko (of Night Watch fame) wrote a series of sci-fi novels set in the Master of Orion universe.

In my review of Age of Em, I said we were very far away from being able to simulate human brains, and sure enough just a few days later Derek Lowe wrote the fascinating Simulating The Brain? Let’s Try Donkey Kong First. Brain simulation proponents hope that without really understanding the brain we can make simple models of each part and how they connect to other parts and produce things that replicate that activity. But we can test these techniques right now on a much simpler and more accessible object – an old video game microprocessor – and they’re not good enough to do anything useful. See also Simulating The Brain. Sure Thing.

A post-mortem of the National Childrens’ Study, which was supposed to be a gold standard for gathering data on early childhood risk, but fell apart because of politics and administrative incompetence.

80,000 Hours’ career guide for people who hate career guides. Lots of statistics on how often each job-search strategy succeeds and fails.

The Devil With Hitler was a 1940s US wartime propaganda film in which Hell wants Hitler to take over from Satan, and Satan has to trick Hitler into performing a good deed to win his position back.

Related: “The present U.S. official position seems to be that Satan may exist and, if so, might be found in New Hampshire.”

Did you know that the Great Pyramid at Giza actually has eight sides? Kind of a weird site, but seems to check out as per the academic literature.

In the game of callout culture, either you win or you die.

Pssst, wanna buy a 92-house town in a National Radio Silence Zone? Only $1 million!

Related: Craigslist for 20 foot trebuchet

Google’s Larry Page has a flying car startup – and a second, competing flying car startup just to motivate the first one. Or at least he had them before someone wrote this article. I don’t know, if somebody says they’re going to give us flying cars but they might stop if it becomes public, I would think twice before publicizing it. And here’s a profile of the flying car design itself.

If Greece was the least neoliberal economy in the developed world, is it fair to blame its failures on neoliberalism?

Rate of innovation in Norway halved after law changed to give universities more of a share of professors’ discoveries.

Motherboard has an article about how censorship on Reddit – it points out that Reddit moderators heavy-handedly censored discussion of the Orlando shooting in unspecified ways, then goes on to condemn it for Donald Trump memes and anti-Hillary conspiracy theories. But it never mentions the whole point of the story it’s reporting about – that Reddit actually censored any information that the shooter was Middle Eastern or motivated by Islamic terrorism. I’m less worried about Reddit censorship (which eventually lifted) than I am about Motherboard’s own distorted reporting which somehow turns a story about excessive political correctness into bashing Reddit for being right-wing.

30% of people would choose to be the other gender if reincarnated, no difference between men and women.

Sam Altman: Nine years of claims that Silicon Valley is a bubble about to burst.

ScienceNews: Bayesian reasoning implicated on some mental disorders. If you’re interested, I wrote a Less Wrong post on this kind of thing back in 2012.

One estimate says that millions of Russians were fooled by a TV documentary claiming that Lenin was a mushroom. Here’s a paper with a little more information than the wiki article. Key quote: “One of the top regional functionaries stated that ‘Lenin could not have been a mushroom’ because ‘a mammal cannot be a plant.'”

Despite the interest in assault rifles when discussing gun violence, Alex Tabarrok finds that rifles as a category account for only 3% of all gun deaths, and fewer total murders than knives, bare hands, or blunt weapons. The real problem is with handguns, which cause about 20x more deaths than all rifles, assault or otherwise.

New study: schools giving out condoms increases teen births. This is just one study about one specific type of situation, and I can think of a few other studies contradicting it, so I won’t quite retract my previous position that the existence of contraceptives probably lowers unplanned pregnancy. But I’m sure glad I’m not the people who were arguing that the position was so stupid that nobody really held it and it was just an excuse for hating women.

Study of 50,000 people who underwent surgery for obesity finds that they have mortality rates only about 30% of those of similar peers who did not have surgery for obesity. Obesity surgery is a really serious operation, and a lot of doctors are scared of it because the side effects might be worse than the disease, but I think this provides very strong evidence that it is very much worth it. I don’t know whether we should lower the threshhold for who gets obesity surgery or not based on these data.

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