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Book Review: The Body Keeps The Score

I.

The Body Keeps The Score is a book about post-traumatic stress disorder.

The author, Bessel van der Kolk, helped discover the condition and lobby for its inclusion in the DSM, and the brief forays into that history are the best part of the book. Like so many things, PTSD feels self-evident once you know about it. But this took decades of conceptual work by people like van der Kolk, crystallizing some ideas and hacking away at others until they ended up with something legible to the Establishment. Before that there was nothing. It was absolutely shocking how much nothing there was. As soon as the APA officialy recognized PTSD as a diagnosis in 1980, Bessel and his friends applied for a grant from the VA to study it. The grant was rejected on the grounds that (actual quote from the rejection letter) “it has never been shown that PTSD is relevant to the mission of the Veterans Administration”. So the first step in raising awareness of PTSD was – amazingly – convincing the US military that some people might get PTSD from combat.

After the military relented, the next step was convincing everyone else. PTSD was temporarily pigeonholed as “the thing veterans get when they come back from a war”. The next push was convincing people that civilian trauma could have similar effects. It was simple to extend the theory to sudden disasters like fires or violent crimes. But van der Kolk and his colleagues started noticing that a history of child abuse, and especially childhood sexual abuse, correlated with a lot of psychiatric problems later on.

Again, “child abuse is bad” sounds self-evident once you know it. But van der Kolk insists this is the result of hard work by a coalition of psychiatrists, psychologists, activists, and victims. When he first started raising awareness of the problem, nobody believed him. His grant proposal to study whether childhood trauma was associated with personality disorders got rejected too. He recalls that:

I was particularly struck by how many female patients spoke of being sexually abused as children. The standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, cocurring about once in every million women. Given that there were then only about one hundred million women in the United States, I wondered how forty-seven, almost half of them, had found their way to my office in the basement of the hospital.

Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology”…the textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis, and allows for a better adjustment to the external world.”

Van der Kolk found that child abuse (sexual and otherwise) was both far more common and far more destructive than anybody else thought. He also found that it worked differently than regular PTSD. A soldier traumatized during war has already developed a sense of self, and has a concept of a safe homeland to return to if he makes it out alive; a child has neither, and has to deal with trauma again and again absent any trustworthy external support system. This is the same insight some researchers call “complex PTSD”; van der Kolk uses the terms “developmental trauma disorder” and argues it is the real culprit behind many people currently diagnosed with ADHD, bipolar, intermittent explosive disorder, oppositional defiant disorder, etc. He rejects at least some of these diagnoses as “pseudoscience…impressive but meaningless labels”.

A group including Van der Kolk tried to get developmental trauma disorder added to the DSM; the APA decided against it. He denounces this decision, which he thinks ignored several great studies that prove developmental trauma (ie child abuse) is much more important than anyone else thinks. I have a lot of opinions about this section.

First, I think van der Kolk downplays the importance of the APA’s philosophical commitment to categorizing by symptoms rather than cause. Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor concentration caused by child abuse. Bob has poor concentration caused by bad genes. Carol throws tantrums because child abuse. Dan throws tantrums because bad genes. The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder? Seems sketchy. When the APA decides not to do that, they’re not necessarily rejecting the seriousness of child abuse, only saying it’s not the kind of thing they build their categories around.

Second, van der Kolk really does not come across as a great source about the effects of development. He does not mention the possibility that links between parent behavior and child pathology might be genetic (ie a disordered parent is more likely to abuse their child, and to pass on genes for disordered behavior). In fact, he is weirdly and vocally ignorant about genetics in general, dismissing the entire field because “after thirty years and millions upon millions of dollars worth of research, we have failed to find consistent genetic patterns for schizophrenia – or for any psychiatric illness, for that matter”. When TBKtS was published in 2014, we already know with certainty that schizophrenia was about 80% genetic, and at least 15 genes had been identified as especially likely to be involved; today we know hundreds and can even make primitive polygenic predictors. The only gene he considers sympathetically is good old 5-HTTLPR, which he says proves that genes have different effects in children with vs. without abuse histories (like everything else about 5-HTTLPR, this has since been proven false). He shows total lack of interest in behavioral genetics and the challenge it raises to his hypothesis.

This is a very pre-replication crisis book. I don’t hold this against the author, I don’t think anyone’s really proud of what they believed pre-replication crisis, but it’s undoubtedly a product of its time. Mirror neurons, candidate genes, left- vs right-brained people, etc all make dramatic appearances. Nothing (except the genetics parts) are inexcusable or even certainly wrong, but all of them together concern me. And several of the book’s key studies are contradicted by later, larger studies. Van der Kolk talks about how childhood trauma decreases IQ, but some pretty good studies say it doesn’t. Even the studies that have passed the test of time look a little weird. The Adverse Childhood Experiences study found that obesity and other seemingly nonpsychiatric diseases were linked to child abuse, and recent studies confirm this – but the controls for socioeconomic status are always insufficient, and there’s surprisingly little shared environmental component. I’m biased about this, everyone’s biased, but part of the book was meant to prove that child abuse mattered shockingly more than you thought it possibly could, and that part was wasted on me.

II.

Fine, okay, drop that hobby horse, what does this book have to say about PTSD?

The book stressed the variety of responses to PTSD. Some people get anxious. Some people get angry. But a lot of people, whatever their other symptoms, also go completely numb. They are probably still “having” “emotions” “under” “the” “surface”, but they have no perception of them. Sometimes this mental deficit is accompanied by equally surprising bodily deficits. Van der Kolk describes a study on stereoagnosia in PTSD patients: if blindfolded and given a small object (like a key), they are unable to recognize it by feel, even though this task is easy for healthy people. Sometimes this gets even more extreme, like the case of a massage therapy patient who did not realize they were being massaged until the therapist verbally acknowledged she had started.

The book is called The Body Keeps The Score, and it returns again and again to the idea of PTSD patients as disconnected from their bodies. The body sends a rich flow of information to the brain, which is part of what we mean when we say we “feel alive” or “feel like I’m in my body”. In PTSD, this flow gets interrupted. People feel “like nothing”. For example:

I don’t know what I feel, it’s like my head and body aren’t connected. I’m living in a tunnel, a fog, no matter what happens it’s the same reaction – numbness, nothing. Having a bubble bath and being burned or raped is the same feeling.

Or, borrowed from one of William James’ patients:

I have no human sensations. I am surrounded by all that can render life happy and agreeable, still to me the faculty of enjoyment and of feeling is wanting. Each of my senses, each part of my proper self, is as it were separated from me and can no longer afford me any feeling; this impossibility seems to depend upon a void which I feel in the front of my head, and to be due to the diminuition of the sensibility over the whole surface of my body, for it seems to me that I never actually reach the objects that I touch. All this would be a small matter enough, but for its frightful result, which is that of the impossibility of any other kind of feeling and of any sort of enjoyment, although I experience a need and desire of them that render my life an incomprehensible torture.

One other new thing I learned about PTSD is the importance of immobilization. Van der Kolk thinks that traumas are much more likely to cause PTSD when the victim is somehow unable to respond to them. Enemy soldiers shooting at you and you are running away = less likelihood of trauma. Enemy soldiers shooting at you and you are hiding motionless behind a tree = more likelihood of trauma. Speculatively, your body feels like its going into trauma mode hasn’t gotten you to take the right actions, and so the trauma mode cannot end.

There’s some discussion of the neurobiology of all this, but it never really connects with the vividness of the anecdotes. A lot of stuff about how trauma causes the lizard brain to inappropriately activate in ways the rational brain can’t control, how your “smoke detector” can be set to overdrive, all backed up with the proper set of big words like “dorsolateral prefrontal cortex” – but none of it seemed to reach the point where I felt like I was making progress to a gears-level explanation. I felt like the level on which I wanted an explanation of PTSD, and the level at which van der Kolk was explaining PTSD, never really connected; I can’t put it any better than that.

Why does PTSD exist? “The brain isn’t prepared to feel emotions as intense as…” Yes it is! Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.

And why would the body be so confused by the right action being “hide” or “accept the pain and abuse” rather than “run” or “fight”? The safest action has been “hide” or “accept the pain and the abuse” in a pretty good fraction of traumatic events since humanity came down from the trees.

And why should the consequences of this be the body going numb? Why not other things that seem more like the consequences of garden-variety acute or chronic stress?

I missed any answers that TBKtS might have contained to questions like these, and so a lot of its neurobiology ended up feeling more like a random collection of simplified facts than like real enlightenment.

III.

But all of this would be excusable if TBKtS had answered the most important question: how do you treat PTSD? There are a wide variety of proposed methods, and I was looking forward to having an authority like van der Kolk sort through the evidence for and against each.

Instead, I felt like he rejected every conventional treatment on the grounds that they didn’t treat the root problem, then waxed rhapsodic about every single weird alternative treatment and how it was a perfect miracle cure that truly gave patients their lives back. I understand that he may just be presenting the alternative treatments that he found most effective, but something about the style here really turned me off.

There are a lot of alternative treatments for PTSD. Neurofeedback, where you attach yourself to a machine that reads your brain waves and try to explore the effect your thoughts have on brain wave production until you are consciously able to manipulate your neural states. Internal family systems, where a therapist guides you through discovering “parts” of yourself (think a weak version of multiple personalities), and you talk to them, and figure out what they want, and make bargains with them where they get what they want and so stop causing mental illness. Eye movement directed reprocessing (alternative when the book was written, now basically establishment) where you move your eyes back and forth while talking about your trauma, and this seems to somehow help you process it better. Acupuncture. Massage. Yoga.

There was a thing called “PBSP psychomotor therapy”, where the therapist would create “tableaus” representing people’s traumas. They would enlist an actor to play the victim’s abusive father, then another actor to play an idealized version of their father who didn’t abuse them and was always there when they needed them, then have them recite formulaic lines that “played their part” in the remembered (or alternative hypothetical) versions of the patient’s trauma. Gradually they would progress from the real trauma to a version where things had worked out better, with the therapist discussing the patient’s reaction the whole time.

There was a chapter on community theater, where troubled youth who would otherwise be sent to jail were instead asked to put on a Shakespeare production. This encountered some early hitches:

We were shocked to discover that, in scenes where someone was in physical danger, the students always sided with the aggressors. Because they could not tolerate any sign of weakness in themselves, they could not accept it in others. They showed nothing but contempt for potential victims, yelling things like “Kill the bitch, she deserves it,” during a skit about dating violence.

At first some of the actors wanted to give up – it was simply too painful to see how mean these kids were – but they stuck it out, and I was amazed to see how they gradually got the students to experiment, however reluctantly, with new roles. Toward the end of the program, a few students were even volunteering for parts that involved showing vulnerability or fear.

The traumatic incidents in Shakespeare’s work helped them come to terms with their own difficult history:

As we’ve seen, the essence of trauma is feeling godforsaken, cut off from the human race. Theater involves a collective confrontation with the realities of the human condition. As Paul Griffin, discussing his theater program for foster care children, told me: “The stuff of tragedy in theater revolves around coping with betrayal, assault, and destruction. These kids have no trouble understanding what Lear, Othello, Macbeth, or Hamlet is all about.” In Tina Packer’s words: “Everything is about using the whole body and having other bodies resonate with your feelings, emotions, and thoughts.” Theater gives trauma survivors a chance to connect with one another by deeply experiencing their common humanity.”

Each of these stories about an alternative therapy was, on its own, inspiring. But after chapter after chapter on these, plus other even weirder things, you start to wish there was at least one alternative therapy that Bessel van der Kolk didn’t like, or one conventional therapy that he did.

This is a very pre-replication-crisis book. In these more cynical days, we know that the first few studies on any technique – usually done in an atmosphere of frothy excitement, by the technique’s most fervent early adapters – are always highly positive. And later studies – done in an atmosphere of boredom, by large multi-center consortia – are almost always disappointing. Half the time van der Kolk is so excited about the miraculous life-changing potential of the latest alternative therapy that he doesn’t list studies at all. The other half of the time, the studies are there to support his enthusiasm. But can they be trusted?

Overall, so many bizarre methods seemed to work so well (with no examples of anything that didn’t work) that it was hard for me to figure out how this book should affect my treatment decisions. Find the closest person in a robe and wizard hat and send all of my trauma patients to them, because every alternative therapy works equally well as long as it’s weird? This might actually be a good lesson, there are a lot of things in psychiatry where as long as people feel drawn in and “validated” the treatment works. But I’m annoyed I have to ponder this kind of thing on my own rather than have the book take a step back and wonder about these kinds of questions.

[Update, written a few weeks after the rest of this post: maybe it is all wizardry. I recommended this book to a severely traumatized patient of mine, who had not benefited from years of conventional treatment, and who wanted to know more about their condition. The next week the patient came in, claiming to be completely cured, and displaying behaviors consistent with this. They did not use any of the techniques in this book, but said that reading the book helped them figure out an indescribable mental motion they could take to resolve their trauma, and that after taking this mental motion their problems were gone. I’m not sure what to think of this or how much I should revise the negative opinion of this book which I formed before this event.]

Maybe the most consistent lesson from this book’s tour of successful alternative therapies – keeping with the theme of the title – is that it’s important for PTSD patients to get back in touch with their bodies. Massage therapy, yoga, and acupuncture addressed this directly, usually creating gentle, comfortable sensations that patients could take note of to gradually relax the absolute firewall between bodily sensation and conscious processing. Some of the other methods – the community theater, maybe even the internal family systems – seemed like tricks to get people afraid of emotions back in touch with their emotions anyway: “Oh, you’re not going to be feeling your emotions, just emotions from Macbeth or Hamlet or this other personality living in your mind”. I don’t know how plausible this interpretation is.

IV.

Overall, I was not too impressed with this book. The highlight was van der Kolk’s personal reminisces from the fight to get PTSD recognized as a real disease – but some of them were so over-the-top that I would have liked to triangulate them with a more objective history. The sections with the symptomatology and neurobiology of PTSD were helpful in exploring the boundaries of the syndrome, but didn’t make me feel like I really understood what was going on. The sections on the dangers of child abuse were a good knock-down of some hypothetical “child abuse isn’t really that bad” position, but I don’t know anyone who holds that position, and some of the research seemed questionable. And the section on treatment was so glowing about everything that it was hard to draw any specific conclusions.

Maybe a broader concern is that I seem to inhabit a different world than van der Kolk. All of his patients showed bizarre and florid sequelae from serious trauma. My patients seem to discuss their trauma with comparative equanimity, have only the usual psychiatric symptoms (depression, anxiety, etc) and not experience much benefit from the weirder alternative therapies they try. Some of this might be van der Kolk being a better doctor than I am, or having sicker patients. But I’m concerned about this because van der Kolk seems pretty good at doing what he does, and I would like to be able to inhabit his world insofar as he’s able to get good results in it. But insofar as my goal is to become more like Bessel van der Kolk, I was surprised how little this book helped guide me along that journey.

I think my actual takeaway is to screen for trauma more carefully, especially in patients who seem anhedonic or numb, and to recommend they go to a trauma clinic. There are a lot of places like this (I sometimes send patients to this one in Berkeley), and they practice a lot of the weirder alternative therapies that van der Kolk mentions (in fact, van der Kolk seems to work at/lead a very similar type of institution in Massachussetts). Whether or not these work for everybody, I think everybody deserves a chance at them, and I should take them more seriously at least until I get a better sense of the terrain here myself.

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221 Responses to Book Review: The Body Keeps The Score

  1. RC-cola-and-a-moon-pie says:

    I recall that George Carlin had a monologue about PTSD being a mere neologism for the more direct phrase “shell shock” used in the First World War. Now I don’t typically take my psychology from comedians but is it really true that the military was reluctant to accept the reality of severe psychological trauma from combat given the well-documented extreme cases we can all watch on grainy recordings from the second decade of the twentieth century? The language of the grant rejection quoted in the text doesn’t clearly question the reality of the condition, and in fact could arguably read to presuppose its veracity.

    • Athreeren says:

      I wonder about that too. Authorities during WW1 had little respect for human life, but a condition that prevented soldiers to return to the fight and made them completely useless in the field, regardless of threats or incentives, had to be extensively studied. How is it possible that PTSD took so long to be recognised, when there was already so much research done on “male hysteria” or “shell shock”? One can question the quality of the research conducted in those days and under such conditions, but I don’t see how one would question the existence of the condition.

    • Aapje says:

      @RC-cola-and-a-moon-pie

      The military has historically been very concerned about desertion and/or not rewarding cowardice.

      Furthermore, WW 1 was the war that changed the view on war significantly, from a very heroic endeavor that turns boys into men, to something that can be a meat grinder that turns boys into corpses and invalids.

      I think that it is hard for modern people to understand the mindset of the day.

      • Paul Brinkley says:

        Another Carlin (Dan) gives a pretty good account of this in his six(!)-part series about WWI. He paints the view of war as a glorious adventure, where anyone could find fortune and renown in daring charges, gallant last stands, and inspiring personal combat. All of this was because of how bespoke war was. The Industrial Revolution hadn’t made its impact felt yet – the only harbinger of things to come was the Russo-Japanese war. Then came the Great War, with its machine guns and trenches and artillery and thousands lost in a single day with no ground gained. Nations had industrial bases now. It took a lot more to knock one out of a fight.

        Which is a bit weird to me – Europe had experienced long wars before. But there it is. Maybe the camera and broadcast media played a key role in bringing it all home.

        • PersonOfInterest says:

          I was going to recommend Dan Carlin’s Blueprint for Armageddon as well. It’s an incredible explanation about the history and legacy of WWI and gives a great account of how soldiers were affected at the time, and how military institutions responded and reacted to the newly seen condition of “Shell Shock”, which we now know as PTSD.

          Specifically, this quote in this post jumped out:

          One other new thing I learned about PTSD is the importance of immobilization. Van der Kolk thinks that traumas are much more likely to cause PTSD when the victim is somehow unable to respond to them… Speculatively, your body feels like its going into trauma mode hasn’t gotten you to take the right actions, and so the trauma mode cannot end.

          Dan Carlin discusses this type of feeling in detail and gives a WWI veteran’s description of what it was like to have gigantic, modern artillery shells constantly exploding all around you. The soldier said it was like being tied to an iron stake and having an executioner repeatedly swing a giant battle ax right at your head, only he misses each time, and hits the solid metal pole an inch above your scalp.

          This was a new form of torture that soldiers hadn’t experienced before. For all of human history, nearly every battle ever fought happened over the span of hours or maybe days, and occurred in an easily identifiable location like “Thermopylae” or “Bunker Hill”. WWI was the first war where battles lasted months, and the battlefield spanned a continent. Soldiers were subjected to incomprehensibly hellish conditions for extended periods of time. They were trapped in a combination trench/sewer/mass grave, unable to affect their surroundings, and all just to gain a few hundred yards of territory, which would be lost to the enemy within a month.

          At the time, military culture held the gallantry of soldierly virtues and heroic self-sacrifice in the highest regard. When the high-ranking military officers saw huge numbers of soldiers fleeing or refusing orders, they considered it a bizarre and egregious form of cowardice, and well-deserving of a firing squad. Eventually, doctors saw it as a traumatic injury, and some suspected it was a physiological response to the huge pressure waves of exploding shells (hence the term “shell shock”). Over time, people recognized the obvious psychological damage of modern warfare and the devastating effects it had.

          Anyways, I highly recommend the podcast series, both for the history lesson and the relevant discussion of the psychological effects of extreme trauma.

        • Aapje says:

          @Paul Brinkley

          I think that there is a big difference between a long, fairly low intensity war vs the extreme experience of WW I. Even Napoleon’s campaign in Russia, which was very extreme for the time, had only a tenth of the casualties of WW I & far fewer battles.

          Also, something that is probably very important: most casualties of Napoleon’s campaign and other pre-modern battles/wars happened during a rout, while WW I ‘punished’ the attacker to an extreme degree. This probably shattered a sense of justice, which is probably more important than the bare number of casualties, when it comes to having or losing a sense of rightness in the world.

          Anyway, Theodore Roosevelt is a good example of someone who saw war as a glorious adventure. Yet when his son died in WW I, it devastated him…

    • ADifferentAnonymous says:

      Dunno about WWI, but the Patton slapping incidents (or rather, the ensuing scandal) seem to show that by WWII the US military establishment believed “shell shock” was a real medical condition.

      • phoenixy says:

        Not to mention the 1946 documentary “Let There be Light” on the topic of shell shock among returning WWII veterans. It was produced by the Army but then suppressed (also by the Army) for fear of reducing enlistment.

    • Reasoner says:

      Here’s the George Carlin bit: https://www.youtube.com/watch?v=hSp8IyaKCs0

    • John Schilling says:

      “Shell Shock” was generally presumed to be a physiological rather than psychological condition, the result of traumatic brain injuries due to the blast effect of nearby exploding shells. Which, to confuse matters, is actually a thing – just not a thing that could explain most of what WWI-era doctors were attributing to “shell shock”.

      Given the general stigma towards mental illness that leads to it being seen as a moral failing, it was “helpful” to have a purely physiological cause to pin everything on, and please to ignore all the “shell-shocked” soldiers who were never actually near an exploding shell. If we say it’s psychological, then we’re saying it’s a moral failing, which in this context is at least adjacent to cowardice. Cowardice in battle has to be extremely discouraged, but nobody wants to shoot or imprison all these sympathetic victims, so just diagnose traumatic brain injuries all around.

      From “shell shock” we get to IIRC “battle fatigue”, which again seems plausibly physiological and not cowardice-adjacent, but doesn’t need the exploding shells. By the time we’re calling it “PTSD”, we(*) are at least somewhat willing to entertain the concept of a mental illness that isn’t a moral failing. Now we can start looking for effective treatments.

      * Meaning the general public, and military decision-makers in particular, rather than mental-health professionals.

      • Mary says:

        Before that we had “soldier’s heart” — also called DaCosta syndrome, after the doctor who figured out that it wasn’t damage to the heart.

      • Spiritkas says:

        Indeed, there does appear to be a strong physical component to soldier’s ptsd and in general anyone who works with loud machinery.

        There were a couple of guests on a Joe Rogan podcast a while back who talk about this. They said one of the biggest issues is a lack of ability to produce hormones after brain damage which lead to a lot of these depression and PTSD symptoms. They have an interesting treatment protocol which overlaps these sorts of mental illnesses with traumatic brain injury in general. Even a simple car accident or banging of the head can do it.

        You can check out the Warrior Angels Foundation as well, where this doctor works with many vets.

        I’ve found some of these protocols to be personally helpful, but I’m not being regularly tested or getting direct testosterone injections as the protocol sometimes calls for. Still it fits in well with the theme of this article and Scott’s general preference for physiological/biological explanations – though it doesn’t address all causes, such as childhood trauma with happens without brain injury.

        http://jrefan.com/the-joe-rogan-experience-episode-1056-with-dr-mark-gordon-and-andrew-marr/

      • konshtok says:

        akshually

        those are 3 different conditions but apparently public discourse can only contain a single combat related mental issue at a time

  2. Lodore says:

    With respect to shell-shock, I guess it’s interesting that trench warfare is exactly the kind of conflict that should generate PTSD on van der Kolk’s view. Being held static for months at a time with shells raining down on you, only to be massed into a sudden assault with high probability of mortality is nightmarish in prospect, let alone for real.

    Given that being drafted (WWI, Vietnam) is itself a form of being held immobile, I wonder if here is higher PTSD in draftees over volunteer soldiers?

    • The original Mr. X says:

      I think that contemporary (post-1900) warfare is more likely to cause PTSD than earlier warfare (even if “months at a time” is an exaggeration — armies in WW1 tended to rotate their units out of the front line after a week or so). In earlier conflicts, you’d have maybe one or two big battles per campaigning season, and each battle would usually be over and done with in a single day; even earlier, before gunpowder weapons became dominant, most people would be fighting hand-to-hand, where they had an opportunity to defend themselves, rather than hiding and hoping that none of the enemy shells happens to land in your position.

      • I wonder if the experience of being in a formation with many other people also tends to help protect against PTSD? It certainly helped armies get soldiers to not run away in the face of danger.

      • Alethenous says:

        I can’t seem to find it, but I remember reading something fascinating about PTSD-like symptoms in ancient armies – specifically, traumatised Roman soldiers were supposedly said to be haunted by the ghosts of those who died around them.

        A great deal of ancient poetry puts a surprising amount of emphasis on the horrors and evils of war, but my suspicion would be that it’s a lot easier to talk about glory and nobility in battle when it’s a question of who puts a spear through whom first than when it’s a question of how many people inhale chlorine and drown in their own blood.

      • Lambert says:

        Also I think WWI was one of the first times when a load of literate people were conscripted to fight.
        It’s possible that pre-moder folks got PTSD, but nobody literate cared about them enough for it to enter the historical record.

        • EchoChaos says:

          The American Civil War was fought between two very literate sides, although the North was more literate at the time.

        • The original Mr. X says:

          Most European countries had conscription during the second half of the 19th century, and literacy levels were pretty high by that time. It’s not like the period was short of wars, either: you had the Franco-Austrian War, the Schlesvig-Holstein War, the Austro-Prussian War, the Franco-Prussian War, the Russo-Turkish War, the Balkan Wars…

        • Janet says:

          What today we call “PTSD” was called “Soldier’s heart” after the American Civil War, and “nostalgia” back to the Revolutionary War era. That was about as early as you can go, and get anything even approximating science and systematic data collection in medicine. This is not a new discovery to society.

          One problem today is that, in veterans, it is often a co-morbidity with traumatic brain injury– even 20 years ago we didn’t understand how micro-trauma can cause major problems with things like working memory, impulsiveness, judgment, etc.

      • bean says:

        This is something I’ve also wondered about. Even a long career in a pre-1850 military was probably fewer days of actual combat than a single tour in Iraq or Afghanistan. But I also remember reading somewhere (On Killing or Acts of War, I think) that it might be partially due to the way we use troops nowdays. During WWII, you usually came home via ship with your unit, or at least with other men who had seen combat. You could talk about it before you had to return to civilian life. Starting in Vietnam, you could be stepping on American soil 24 hours after you got out of the jungle. Vietnam also had the problem of stupid rotation policies, where you got separated from your unit on return.

        • The original Mr. X says:

          Ancient city-states often fought wars quite close to the home city (according to Google Maps, for example, you could walk from Athens to Marathon in under eight hours), although I suppose in those societies the army tended to be a citizen militia, so even in civilian life you’d be interacting with many of the same people whom you’d fought alongside (ETA and hence could talk with them about what had happened). Lots of cultures apparently also had ritual cleansing ceremonies for soldiers returning from battle, which I suppose would also help to mark a clear transition to civilian life (and hence no need for continued vigilance and the like).

          • bean says:

            Those rituals were actually mentioned in the book as another example of the same process. And even if you were an Athenian who fought at Marathon, you probably weren’t spit out back to civilian life the next day. Time spent theoretically still on duty after the battle would still probably count for decompression.

          • The original Mr. X says:

            I think it would depend on the exact situation. Most city-states had very small territory — less than a day’s walk in each direction, in many cases — and if you were called out to, say, drive off a raiding party from the next city, you could well march out, fight, and return to the city within a day. And in the case of Marathon specifically, the Athenian army hurried back immediately to stop the Persian fleet reaching Athens while they were away. So in such societies, I think that specific end-of-battle or end-of-campaigning rituals, and the general militarisation of society, would be more important in preventing PTSD.

        • Nornagest says:

          Probably On Killing. I remember the argument, and I’ve read that but haven’t read Acts of War.

          I’ve gotten pretty skeptical of Grossman since then, though.

        • JohnBuridan says:

          This is also discussed in Shay’s books about PTSD Achilles in Vietnam, whose patient testimonials emphasizes the way in which US command deployed soldiers and officers by a method which seemed to maximize the amount of trauma they would experience and diminish their ability to psychologically recover from battlefield situations.

          Specifically, extended times in the field, constant rotations of soldiers and commanders in platoons and companies weakening comradery, the M-16, unfair practices by officers when on patrol putting the same guy on point multiple times in a row, requesting and being denied air support or artillery support in a hot zone (pretty rare though, I think).

      • Don_Flamingo says:

        The Germans didn’t rotate as much, tended to mostly use their troops up, so when they sent people to the trenches they were all fresh and motivated.

    • eliasgoldberg says:

      It’s also exactly the kind of conflict that should generate traumatic brain injury, since World War I saw the first wide scale use of high explosive artillery shells. George Carlin’s bit was about how political correctness obscures the true nature of things via euphemism, and he might have been more right than he knew. Research into PTSD during the wars in Iraq and Afghanistan showed almost no correlation between the horribleness of the wartime experience (in terms of injuries suffered, gore observed, friends dead, subjective perception of danger, etc) and the rate of PTSD. There was a great deal of correlation between proximity to explosions and PTSD. The term “Shell Shock” actually contained a really important clue as to the cause of the condition, and that clue was lost as we kept changing the condition’s name.

      Learning all this has made me extremely skeptical that the condition suffered by soldiers in war has anything to do with the condition suffered by victims of childhood sexual abuse. I’m sure both are equally real and equally serious, but trying to apply the same treatment to both may be a misstep.

  3. Joy says:

    C-PTSD is completely different from PTSD. PTSD is what the war vets get, C-PTSD is what a child who is abused daily with no escape gets. PTSD can be treated with EMDR and exposure therapy, C-PTSD is interwoven into the person’s psyche, because the trauma with no escape was there throughout a significant part of their formative years, and so there are zillions of different traumatic events memories of which the child suppressed in order to survive. EMDR, exposure therapy and other kinds of trauma therapy destabilize the walled compartments and overwhelm the delicate balance, often leading to retraumatizing, lasting depression, suicidality and general decrease in the quality of life. Yet the therapists tend to use PTSD techniques on C-PTSD survivors, with predictably ill results. There are some promising pharmacological treatments, like the current MDMA trials, and therapies, like healing a wounded inner child, or, more recently, working on Internal Family Systems. Also, consider having a look at Pete Walker’s book Complex PTSD: From Surviving to Thriving. Maybe you can review it at some point.

    • Aapje says:

      This matches with my intuitions/experiences. I’d be interested in that review.

    • alwhite says:

      In line with Van der Kolk’s efforts. C-PTSD is not a recognized diagnosis unlike PTSD. We can’t get approved therapies for C-PTSD because we can’t get research grants for diagnoses that don’t exist. Thus people use the treatments that do get funded and label the outer treatments as “woo” because the system won’t recognize C-PTSD as a legitimate thing.

      I have training in IFS and like it a lot. I think it helps people feel safe and in control when exploring their past traumas.

    • Solra Bizna says:

      Well, now I feel like I’ve dodged a bullet by not yet starting EMDR. Your comment prompted me to see in a new light the rapid and serious decline my quality of life took when I started conventional PTSD treatment for my C-PTSD. (Concrete example: I was able to brush my teeth at least once or twice a week before treatment. Now it’s barely once a year, even using every trick in the book.)

    • LeeBird says:

      I had been considering EMDR for what I believe are C-PTSD symptoms; I will not be seeking that out now, so thank you.

      I tried MDMA for the first time in 2015 and it was essentially the beginning of my “real” life. Up until that time, I was so emotionally over-regulated that I didn’t even realize I needed help.

    • thrilledcodex says:

      This also matches my experiences. I think C-PTSD is probably worth recognizing as different than PTSD because the symptoms and treatment are significantly different. I can respect that there might not yet be sufficient evidence to add it to the DSM, but I don’t think the “bad gene disorder” analogy in this review is fair.

      I second the recommendation for Pete Walker’s book for what it is worth.

    • Joy says:

      Those interested in an accessible yet academic-level discussion of C-PTSD, I warmly recommend this blog. The author has since focused on sex blogging with emphasis on mental health, so not linking it here, but a search for “deviant succubus” will get you there.

  4. Nancy Lebovitz says:

    I think Betrayal Trauma: The Logic of Forgetting Childhood Abuse would be worth reviewing– it’s based on the theory that people are more likely to forget abuse if acknowledging it would risk losing needed support. And the forgetting can work more strongly than I would have thought– it’s possible tor children to be abused nightly and forget during the day.

    The book has a deep dive into how memory works and evidence about remembering and forgetting traumatic events.

  5. echidna says:

    There was a recent This Ameican Life episode about CPT: cognitive behavioral therapy for PTSD (https://www.thisamericanlife.org/682/ten-sessions). Does anyone have an informed view about CPT?

    • alwhite says:

      The VA has a specific CBT protocol for treating PTSD. Many people see it as re-traumatizing and most veterans who undergo the treatment dislike it and prefer something else. Is that protocol CPT? I don’t know. CBT has expanded in so many ways that you can classify a lot of stuff as CBT without being CBT.

    • cuke says:

      Trauma is a focus of my work and I use CPT a lot in my psychotherapy practice.

      I really believe the research showing that most all therapy techniques are more or less equal in the context of a trusting, therapeutic relationship where the common therapeutic factors are in place. Having said that, all techniques are not equally effective for all people, so part of the challenge is finding the way in for each individual person.

      CPT is good for folks who are fairly articulate and can access their cognitive functions easily, even when somewhat distressed.

      For people who lack insight into their emotional turbulence, who are very well defended, who dissociate under stress, or who are not big verbal processors, there may be better options.

      All the different flavors of trauma treatment are different roads into “trauma processing” — which is really just a way for a person to sit down with and face the horror of their experience and its impact on them in the presence of a safe witness/guide. Which approach a therapist takes should depend mostly on the learning/processing style of the client, but often depends instead on the latest fad in psychotherapy or what that therapist feels most comfortable doing.

      Trauma has a way of freezing people’s development in various ways and so trauma processing is not always the end of it (sometimes it is), and the person needs help bringing along underdeveloped parts of themselves. Chronic neglect or abuse in childhood tend to produce adults who chronically neglect and abuse themselves, to put it simplistically.

    • JohnBuridan says:

      I have a personal anecdote about use of CBT. I have found it a helpful way of classifying and deconstructing my neuroses. I had had an extended traumatic experience which, I think, would be classified as PTSD, although it was not diagnosed. Psychologist described to me CBT especially the book Schema Therapy which he allowed me to borrow. After about two months, I was able to quickly recognize when I was actualizing the cycle of spiralling thoughts and take a step back to stop from that downward slope.

      I have to say though, that there is, of course, more to full flourishing than control over one’s thoughts. My environment changed too. The people around me were more well-adjusted, positive, and supportive. That also released a lot of the psychological tension and diminished the likelihood of these wild psychological reactions.

  6. eric23 says:

    The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder?

    This is exactly how successful medicine works. Understanding what causes a disease is very often necessary to successfully treat it.

    Imagine four people who have headaches. The “current DSM” method would classify all of them as having the “headache” disease. An actual medical investigation would find that one has the flu, one was over-stressed at work, one just had a stroke, and one is dehydrated. Knowing this, each of them could then get the treatment which works for them.

    Van der Kolk is proposing one explanation of the causes. Is it right? Who knows, but we can think of ways to test it. If it turns out to be right, we are that much closer to a treatment. If not, we can try a different explanation.

    • Aapje says:

      Indeed. This insistence on categorizing crude symptoms may be why psychiatry progresses so slowly and appears incapable of handling more complex things like autism.

      • Ketil says:

        What is the evidence that any causal explanation is correct? What is the evidence that any treatment works?

        I’m probably way to uncharitable towards psychology as a field, but with a few exceptions, it seems riddled with completely ad hoc hypotheses and argued by deference to authority, and diagnoses appear to rise and fall based on factors like societal acceptance, reward, opportunity, and downright fashion.

        Where is the rationalist approach to all of this?

    • Cheese says:

      That’s not really true in psychiatry. We don’t really have good causitive biological models of, well, basically most of the common psychiatric entities.

      When we do, we might be able to group and treat via cause. Although, equally, we might not given there’s probably a neurodevelopmental component to a lot of them.

      As it currently stands, I really can’t see how anyone can advocate not grouping by symptoms. It’s the best system we’ve got and it categorises people who respond to different treatments well.

    • Scott Alexander says:

      I think this is complicated and depends on (among other things) to what degree our current treatments are symptomatic vs. disease-modifying.

      Suppose you have pain in your arm due to a bacterial infection. A symptomatic treatment would be Advil (reduces pain regardless of what the cause is). A disease-modifying treatment would be antibiotics (kills bacteria regardless of what symptoms they are causing).

      I don’t think there’s an official position about which of these categories psych treatments fall into. I suspect the drugs are mostly symptomatic – for example, antidepressants will reduce depressed feelings around the death of a loved one. This maybe bleeds into disease-modification – I think stress reinforces depression, so if the antidepressant is just making you less stressed, that in itself can help the depression go away at the root – but all of this is wild speculation.

      Antipsychotics are close to disease-modifying (there’s some evidence they can arrest the progression of schizophrenia or prevent prodromes from turning into full schizophrenia), but they’re also clearly symptomatic on some level (e.g. they work both on bipolar psychosis and schizophrenic psychosis, and they even seem to work a little for dementia psychosis).

      If you mostly have symptomatic treatments, you should probably use symptomatic categories; if you mostly have disease-modifying treatments, you should probably use disease-modifying categories. This is just my opinion and I’ve never heard any official APA or DSM people talk about things at this level before (though I’m sure it’s happening somewhere).

      • Aapje says:

        If you mostly have symptomatic treatments, you should probably use symptomatic categories; if you mostly have disease-modifying treatments, you should probably use disease-modifying categories.

        And if you have both, you might need both kinds of categories, instead of dogmatically choosing one.

    • Darwin says:

      But imagine that medical science were still in its earliest stages, and the best treatment it had for any type of headache, regardless of underlying causation, was to prescribe aspirin to treat the symptoms.

      In that case, classifying all those headaches together makes a lot more sense.

      Psychology and psychiatry are still maturing, and treating symptoms for lack of a better option is still very common. This is also complicated by the fact that many conditions get moved from psychology to medicine once we understand the root biological cause and have a standard medical treatment for it.

      • cuke says:

        I agree with this view.

        The DSM is structured the way it is because we don’t understand causes in mental illness. There are some pretty big areas of non-psychiatric medicine that are also this way — all kinds of chronic conditions, gut illness, back pains, neuropathies, and so on. Even with something like diabetes or hypertension or hearing loss, we are treating symptoms and we have some ideas about risk factors. But it’s not like, X bug causes Y infection, and so we apply Z medicine which kills X bug. Infections and mechanical problems where causes are readily apparent are a big part of medicine, but by no means all of it.

        PTSD is one of a very few psychiatric conditions that is definitionally anchored to a cause — ie, a traumatic experience.

        Even with knowledge of that cause, though, it’s a cause that happened in the past and cannot be undone, so we can’t go “fix” the cause.

        Even with PTSD, we don’t understand why some people who experience trauma don’t develop PTSD and others do. We can say some things about risk factors, but that’s all.

        In 2013, new head of the NIMH Tom Insel launched a big effort to re-write our psychiatric nosology around biological causes for mental illness (called RDoC or Research Domain Criteria). Insel left two years later and I think this effort has only limped along because we simply don’t have the science yet.

  7. Blueberry pie says:

    I have some experience in running personal-growth retreats for young adults (completely volunteer-run, within the Scout organization in my country). Some of the people I worked with had psychological/psychotherapeutical education and spoke a lot about “connecting with your body”, “understanding your emotions through your body” or “being IN your body” and similar stuff broadly in-line with what I understand the book to be about. And for what it’s worth, I’ve found this framework to be quite useful in designing activities and experiences that the participants mostly enjoyed and in retrospect rated as positive, helpful, sometimes even life-transforming.

    I don’t claim it is true, just that it helped me – as someone who tends to be quite rational and has relatively shallow emotions – think about psychological processes in others and design activities that help them grow as persons.

    • LeeBird says:

      Speaking as someone who has felt like an advanced consciousness trapped in a primitive meat vessel for most of my life, I agree with your retreat participants. Mindless physical activity often creates a state of “flow” that is liberating and pleasurable.

      • Don_Flamingo says:

        I mostly go out in light clothing even in winter and this year, even should there be snow and ice this year.
        A because I can
        B because it feels exhilarating
        Nothing better for getting in your body, than having all those normally equilibrated-and-bored-out-of-their-skull thermal receptors all start screaming at the same time.

        And I really need that. Shallow emotions and if I don’t pay attention, dull apathy.

  8. Joyous says:

    This comment isn’t related to the main theme of Scott’s post, but is in regards to the “APA’s philosophical commitment to categorizing by symptoms rather than cause.” I think this approach might be counterproductive and inaccurate in some cases. For example, there is significant overlap or comorbidity among anxiety disorders. As a pre-teen I was diagnosed with OCD, GAD, *and* panic disorder with agoraphobia, based on having symptoms that met the criteria for each. Believing that I had three separate and unrelated disorders was devastating. On the other hand, there was a 19th/early-20th century concept of “neurasthenia” that basically grouped all of the anxiety disorders together based on the proposed common cause of an “over-reactive” nervous system. Patients often shifted between various symptoms, and benefited from a common treatment for all. Believing that I had a neurasthenic phenotype that could cause various symptoms of anxiety didn’t seem as bad/unusual/isolating as having three disorders. If there is a genetic basis for an anxious temperament, then categorizing the disorders based on a common cause would seem to be an appropriate model.

    • Scott Alexander says:

      Your experience seems pretty typical, but I’m not sure this is a failure of grouping by symptoms rather than cause – all the symptoms you describe tend to run together, so a good symptomatic grouping system should classify them as one condition!

      I think the problem here is just that the categories are too fuzzy – if people with depressed mood are 80% likely to have low energy, 50% likely to have anxiety, and 20% likely to have obsessions/compulsions, at some point you need to arbitrarily group (mood, energy) together as “one disease”, and (mood, energy)(anxiety) separately as two highly comorbid diseases. This is naturally going to be an unprincipled or barely-principled distinction. Borsboom et al’s idea of symptom networks rather than diseases tries to address this problem, but it’s a lot harder to understand and work with than the traditional system.

    • LeeBird says:

      If it were easier to find the common cause, I suspect our diagnostic methods would change dramatically. As it stands, professionals like to work with that which they can observe, so symptom-based criteria is the standard.

      • cuke says:

        I don’t know this for sure, but I suspect that “cause” when it comes to anxiety is like “cause” when it comes to cancer, which is to say it’s a mix of genetics and environment. Same perhaps with autism or autoimmune disorders.

        The DSM always asks “is this presentation of symptoms better accounted for by a medical condition?” and so it’s important to test for hyper or hypo thyroid, anemia, drug-induced anxiety or agitation, etc.

        Some people’s anxiety is almost entirely stress-induced — which is to say, they have no history of anxiety but it came on when their sick, elderly mother moved in with them or when their daughter developed a heroin habit.

        So for now, the DSM is just a way to corral symptoms and says nothing about causes or treatment. It just gives us a shared language — but mainly, a way to bill for insurance. It’s not a very impressive book at the end of the day, but we also don’t have something better.

    • cuke says:

      This is so well said, both about the big overlap between anxiety “disorders” and the impact from a patient’s point of view of being overly-labeled and inadequately understood.

      It’s particularly odd when our treatments — whether medication or talk therapy — are not specific enough to differentiate between treatments for one or the other type of anxiety.

      This doesn’t counter anything you say here. I would only add that as a clinician who mainly treats anxiety and PTSD that having names for the different flavors or manifestations of these conditions and having research and writing that speaks about these different flavors is helpful.

      There is writing about anxiety research and treatment that proposes different causes for these different flavors but my impression is that this is more speculative or impressionistic based on lots of clinical experience rather than being actual science.

  9. pancrea says:

    I’m confused by the image on that book cover. It looks like this person has two legs, one naked boob, and… four arms? Two arms and two bunny ears, perhaps? And her head is weirdly bulbous.

    What is this image trying to convey?

    — I mean, I assume it’s trying to convey “people who have trauma tend to have a strange connection to their bodies and this twisted deformed image of a body represents that strange connection”. I just don’t get that very well from this image of a person with a naked boob and bunny ears.

  10. Don_Flamingo says:

    ”…the textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis, and allows for a better adjustment to the external world.”

    Yes, yes of course. As Nietzsche said: “What doesn’t kill you, makes you stronger.”

    More seriously I’d want to see that standard textbook, before I just believe that claim.
    It sounds on the surface preposterous.
    Sure, it’s medicine and of that psychiatry….. but that sounds extraordinarily stupid and downright perverse by pretty much any cultural standard in human history.
    And if it was a standard textbook, were there other textbooks as well with wildly different ideas? Is this some Freud fetish or Lancan fetish rearing its ugly head? Did anyone ever take that claim seriously?
    Did psychiatrists ever tell their patients to diddle their daughter or encourage pedophiles?

    I don’t mean to say that van der Kolk is making this up or that this is even wrong, just that it would be nice to know a little more about this.
    Could you or someone else expand on this? I have trouble believing it or at least don’t know what to make of it.

    • Aron Wall says:

      Not a direct answer to your question, but FWIW, I once went to an estate sale where the decedant was, judging from the items for sale, a professional psychotherapist of some sort. I purchased a few books and one of them was a pop-level book written by an apparently serious and credentialed psychologist, who in one of the chapters advocated for incestuous interest from parents to pubescent children as a normal and healthy part of development… basically the exact same answer he gave for masturbation or homosexuality: “no big deal, get over silly taboos”.

      I think his ideology was something like: as long as everyone treated sexuality as a completely normal, guilt free thing, then nobody would end up with any neurotic troubles from it. The 60’s were a weird time.

      My ability to recall further details (e.g. author, title) is hampered by the fact that I didn’t want that book on my shelf, and also didn’t want to give it away to anyone, so I threw it in the garbage.

      • Don_Flamingo says:

        I suppose so.
        I’m unaware of the history of the field. What does credentialed and standard mean in the sixties?
        Standard textbook implies that this was consensus, but I’d have trouble believing that.
        And if that was consensus among psychiatrist, I’d expect psychiatry itself to be this fringe thing, that noone took all too seriously.
        Though when watching “Annie Hall” I get the impression that psychiatry was mostly an odd Jewish cultural practice, rather than a field of medicine. The German title of this movie is “der Stadtneurotiker” (the city neurotic) being more true to what the film is about.

        • Aron Wall says:

          As I implied, my memories of the book are rather fuzzy now, but IIRC he had “Dr.” in front of his name and saw patients…

          I’m just providing one data point, not making a claim about what was “mainstream” then in the sense of consensus. I was born in 1984; I wasn’t there. But I’m guessing that things would go very differently if a clinician tried to advocate for parental incest in print today…

      • DarkTigger says:

        I mean, I heared there where those people that argued stuff like that. But were they ever the mainstream?

        • Mark Atwood says:

          But were they ever the mainstream?

          Talk psychotherapy itself was not “mainstream” then. People knew it existed, because it was portrayed in fiction, mostly as something that “rich people from New York did” or “something that anxious parents sent their sullen teenager to to talk to someone with a diploma”, but what the actors lines were likely barely related to what the advanced textbooks said or what was spoken in sessions.

      • Mark Atwood says:

        I’m pretty sure I read a copy of that book, or one substantially like it.

        It was a library book, so I couldn’t throw it in the trash.

        The 60s and 70s were a weird and more than a little bit disgusting time.

        • dark orchid says:

          There was a fairly well-known educator where I grew up who wrote a lot like this, saying things like “the teacher should appear to the pupil as a sexual being” and trying to “liberate” people from old-fashioned taboos about sexuality. He also was very supportive of “progressive” education and a lot of his theories sort of became dogma in the local teacher training institute.

          It turned out recently that he was also a serial child abuser.

    • noyann says:

      > but that sounds extraordinarily stupid and downright perverse by pretty much any cultural standard in human history.

      Not quite. Some native tribes let their babies cry on purpose for a while, because it would make more ferocious warriors. [citation needed]

    • Googling for the quote, I found another reference with more details. The book was Freedman and Kaplan’s Comprehensive Textbook of Psychiatry. With regard to father-daughter incest, it asserts that “the vast majority of them were none the worse for the experience.”

      ,

  11. ownshoes says:

    Like Scott’s patient, I experienced tremendous breakthroughs with respect to my mental health after reading this book. I already knew I had anhedonia and the related difficulties in motivating myself, and thought I was on the way to fixing this because therapy had helped me come to a conceptual understanding of the childhood experiences behind the numbness. But I didn’t know what I didn’t know… this book evoked the frozen and lifeless quality of trauma in a way that resonated so strongly I could no longer deny that there was trauma involved with my problems. It made me realise that there was a whole series of internal sensations and processes that I was actively missing. As a result I then read In An Unspoken Voice by Peter Levine, and by following the exercises in that book I’ve made inroads into resolving that trauma and becoming a happier and more effective creature. While I was also annoyed by the breathless sections on whatever fad treatment had popped up, I’m nevertheless tremendously grateful for this book.

    If people want a summary, this paper by Levine and chums goes over the method and the proposed pathways by which it might work. I haven’t really interrogated the sources but I’d be interested to hear thoughts from people with subject expertise: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316402

    • LeeBird says:

      adding Levine to my reading list; thank you!

    • cuke says:

      This is so cool to hear.

      I’m interested in this phenomenon more broadly. There are lots of folks who say their back (or other mystery) pain resolved after reading John Sarno’s books.

      For pain that is psychogenic in nature, whether the pain is emotional or physical, it seems a receptive mind is a good thing, and in that way, reading a book is not so different from talking to a therapist.

      I’ve had clients come see me for just a couple of sessions because they noticed a huge improvement in their presenting problem after they called to schedule an appointment and before showing up to meet me (there’s research about this, btw). We just have a couple of sessions to make sure that result sticks.

  12. Don_Flamingo says:

    re: ADHD
    I thought that ADHD was fairly well understood on a neurological level these days?
    Does the author discuss the proposed 30% reduced “executive age” in children affected with ADHD?
    https://www.youtube.com/watch?v=BzhbAK1pdPM&list=PLzBixSjmbc8eFl6UX5_wWGP8i0mAs-cvY

    From what I understand, Dr. Russel Barkley is a leading ADHD researcher and this is the latest understanding of ADHD and that anyone that doesn’t discuss in 2015, what was known in 2014 already has no standing to discuss ADHD at all? Perhaps van der Kolk does discuss it and you just haven’t quoted that passage.

  13. smilerz says:

    Were the misspellings in the excerpt about the Shakespeare production in the original or transcription errors?

  14. alwhite says:

    I have done training at The Trauma Center which is Van der Kolk’s organization. I think, Scott, you have some misunderstandings.

    But first, I’m not all that impressed by genetic studies. Every genetic study carries with it the family lineage of abuse, so a person who inherits from their abusive parent, who inherits from their abusive parent, is a trend that goes back forever. Our not so distant past was sufficiently difficult and traumatizing that it’s not too far a stretch to understand way more people are dealing with traumatic effects than we admit. (I work with people who literally say everything is trauma. I don’t believe this, but I think it’s relevant to expand our concept of trauma even further than what ACEs might imply) So, to say that genetics disproves the trauma theory, to me, seems suspect. As you asked about the book “how do you treat PTSD?” I ask as well, “how do you treat genetics?”. With trauma, there’s a path of change that I think I see working, with genetics, I’m hopeless. As you said in the symptoms section “bad gene disorder?” If you think bad gene disorder is a sketchy response to classifying disorders why is bad gene disorder not a sketchy explanation for why this stuff happens?

    Second, I think you’re completely wrong about the APA’s philosophical commitment to categorizing by symptom vs cause. Thomas Insel and NIMH have hammered the APA on this point many times. It’s bad science. Many diseases have similar symptoms and yet need treated differently. Treating symptoms never leads to cures, just coping with the underlying disease.

    On to specific misconceptions. I think you’re missing something about immobilization because the way you wrote about it seemed off. Immobilization isn’t a choice in the moment, it’s a part of the environment in that moment. A person who is trapped in a car crash and watches a person die with no chance of action, will be more traumatized than a person who had the option to try to help that person when they still died. Your example of hiding behind a tree, isn’t exactly the same because the choice to hide as the best option is there. In children, their worldview is so shaped by their parents, that options like “run away” seem impossible and thus they feel trapped by their abuser. The immobilization is about the feeling of trapped and powerless.

    How this connects to the body. We often say that trauma is memories that the mind hasn’t accurately placed in the past, always present. Specific symptoms of PTSD like hyper vigilance, intrusive memories, night terrors, flashbacks, etc. We see all of these as memories appearing in the present context and being removed of their appropriate time stamp. By getting people to reprocess the memory in it’s appropriate temporal context, we “cure” the PTSD. This is the basis of the VA’s CBT Protocol. It’s the theory behind EMDR. And so on. The body part is that these memories aren’t stored in our explicit memories that most people think of, but our implicit memories that are body sense related. Neurologically, things like the hippo-campus for explicit and amygdala for implicit. (Brain Based Therapy is a good book on this) In traumatic events, the senses that are associated with the trauma get tied to the stuck memories, so that the sensation re-triggers the traumatic memory and we relive it. Firecrackers setting off veterans kind of thing. Or a particular smell of cologne that matched the abusive uncle.

    Treating this kind of trauma requires understanding more senses in the brain. We have 8 senses. The typical 5 plus vestibular, proprioception, and interoception. Vestibular, sense of balance located in the inner ear. Proprioception is the sense of where your body is in relation to itself. Close your eyes and have someone move your foot up or down. Proprioception is your ability to know which direction your foot is facing. Interoception is your internal senses of how your body is feeling; temperature, hunger, emotions. Treating trauma often involves reteaching how to sense Proprioception and interoception without getting retriggered. It’s separating the sensations from the memories. Yoga is a good tool for this because it’s focuses so heavily on the body sensations while giving enough distraction that the mind doesn’t think too hard about the memories. The other weird stuff that Van der Kolk introduces is about reprocessing the memories from present to past. There’s probably lots of ways that works and his specific examples are just the ones he encountered.

    Finally, we have to deal with the reality of vulnerability. As an emotion, it kind of sucks. People with traumatic histories, even mildly traumatic as described in some of the ACEs material, can be really sensitive to the emotion of vulnerability. Being intolerant of vulnerability, makes it really hard to have good emotional connection with other people. Situations that produce this kind of intolerance don’t have to be all that bad but I would still classify them as trauma-like. A person who was never beat as child, but was always punished (extra chores) when they made a mistake (as children do), learns as an adult that making mistakes is unacceptable. Therefore, they will deny any wrong doing ever thus creating fights with their spouse. (I have a client with this exact situation) This isn’t TRAUMA, but it’s trauma like. We’re working on picking out the sensations and emotions that happen in that moment and learning to attach the sensations to the past instead of the present moment so they can respond differently in the present.

    That’s an overview of things I think you’re missing. It’s been a while since I read The Body Keeps the Score. Some of this information may not be in that book and stuff I picked up elsewhere. I still don’t think the APA takes trauma seriously enough and that a lot of the diagnoses we have are just manifestations of the same thing. I think it’s a real disservice and harm to patients, that this is so.

    • Aapje says:

      But first, I’m not all that impressed by genetic studies. Every genetic study carries with it the family lineage of abuse, so a person who inherits from their abusive parent, who inherits from their abusive parent, is a trend that goes back forever.

      This is not an issue with bullying, yet genetic factors are still significantly correlated.

      • alwhite says:

        I don’t understand what you mean by this not being an issue with bullying. Family transmission has long been an issue with bullying.

        First, with respect to victimization, Allison et al. (2014) showed that a parents’ past history of victimization is associated with an increased risk of their offspring being victimized. Whereas only 25% of the parents without a past history of being bullied reported that their offspring was victimized, in the case of parents, who had been victimized themselves, this proportion was 55%. Second, with respect to perpetration, Farrington (1993) observed a comparable inter-generational continuity. Whereas only 5.5% of the fathers who did not bully had children who bullied, 16% of the fathers who were bullies reported that their children were bullies as well. Together, these family-risk studies show that perpetration and victimization are familial, but not whether this familial transmission is genetic or environmental in nature.

        Furthermore, the twin study did not exclude being raised by the same parents, thus the twins were raised by the same parent that was bullied/perpetrated. The appropriate study would be to study twins that were adopted instead of raised by biological parents. They did not appropriately isolate the home environment from the test variables. I don’t see the study proving much.

        • Cliff says:

          Well someone who is bullied as a kid, how are they going to transmit that environmentally to their kid so that the kid is also bullied? Fathers who beat children who beat their children is plausible, but how would it work for people who were bullied? I’m sure you an make up some kind of story, but given the extremely small effects of shared environment they would seem implausible.

          • acymetric says:

            I’m not 100% on board with this, but I would think it would go something like: father who was bullied still carries the behaviors/social cues and/or values that lead to being a target of bullying. The child picks up some of these things from being around/learning from/mimicking the father and becomes a target themselves. Same for bullies with bully type behavior.

    • Scott Alexander says:

      “But first, I’m not all that impressed by genetic studies. Every genetic study carries with it the family lineage of abuse, so a person who inherits from their abusive parent, who inherits from their abusive parent, is a trend that goes back forever.”

      I’m a little confused what you mean. My stab at interpreting this is something like “Genetics is confounded by abuse, because you don’t just inherit genes from your parents but also whatever abuse they inflict on you”. But the studies are designed to compare monozygotic vs. dizygotic twins to avoid exactly this possibility. You mention the division by ACE later in your comment, so it sounds like you’re aware of this – what am I missing here?

      “Second, I think you’re completely wrong about the APA’s philosophical commitment to categorizing by symptom vs cause. Thomas Insel and NIMH have hammered the APA on this point many times. It’s bad science. Many diseases have similar symptoms and yet need treated differently. Treating symptoms never leads to cures, just coping with the underlying disease.”

      Wrong that this is in fact the APA’s current commitment? Or wrong that the commitment is a good idea, which I didn’t assert and am not sure I want to defend (though see my response here)?

      My impression is that Insel has given the world a giant promissory note marked “IOU a good ontology based on causes of psychiatric conditions”, then mostly failed to deliver. I agree it is a good idea for a research program, but you can’t actually use it until the research program has born fruit, which so far it hasn’t.

      I really appreciated the rest of your comment; thanks for sharing your expertise on this issue.

      • alwhite says:

        On the genetics, I’m not sure you’re missing much. I’m just expressing skepticism. I understand the studies being done but something just doesn’t seem right to me and when people try to use genetics to confound trauma explanations, I think we’re heading down the wrong path. And I guess I see that here. Your comments were criticizing van der Kolk about ignoring genetics but so often I see genetics explanations ignoring trauma.

        Related to the second point on APA, there seems to be a really strong effort to ignore childhood abuse as a cause of disorders. It’s the battle over the medical model of mental health and maybe more specifically the biological model of mental health, and the nature v nurture debate as well. It really does feel like the APA wants everything to be biological and nature based with no room for nurture and trauma to play a role. In a simplistic example, a person who was raised by terrible parents and was told they were unlovable all the time for the first 18 years of their life (I’ve known clients who have had this kind of life). The APA and DSM say said person has bipolar disorder which is biologically based, maybe genetically caused and the only thing that will help is some medication to alter brain states. But, I also think there’s a lot of benefit to help that person grieve the pain they suffered, and retrain some deep beliefs about themselves and how the world works. A lot of those people don’t believe they’re lovable because the very beginning of their existence was saturated in messages that they’re not lovable and therapy is sometimes just the long slog into believing something different. The biological and genetic model doesn’t seem to have room for this so that even genetics studies that somehow prove something, I’m still skeptical of.

        Murray Bowen did an experiment in the 80s where he “cured” a child of schizophrenia by helping the family improve their behavior towards each other. This bleeds into the next argument, we need to understand causes for doing correct diagnosis. Was the child actually cured? Was the child given the correct diagnosis? I tend to explain Bowen’s findings as bad diagnosis, but this also assumes that schizophrenia is genetic. Meaning, child didn’t have schizophrenia but simply behaved as if they did because family was so messed up. But with the symptoms based approach, how could we even tell?

        To clarify my statement, you said van der Kolk downplayed the importance of the symptoms based approach, and I think that importance is wrong. I guess that sentence reads to me like you endorse the APA’s stance and I find that stance really problematic. Like above, I definitely believe that multiple causes can create similar symptoms and we end up treating the wrong thing if we rely on symptoms only approaches, which is what the DSM is.

        I agree that Insel made promises that never got followed up on, but I don’t think that undermines the original complaints about the system not being rigorous enough.

    • Cliff says:

      A person who was never beat as child, but was always punished (extra chores) when they made a mistake (as children do), learns as an adult that making mistakes is unacceptable. Therefore, they will deny any wrong doing ever thus creating fights with their spouse.

      This smacks to me of a just-so story, like a lot of pop evolutionary psychology.

  15. Eri says:

    > Why does PTSD exist? “The brain isn’t prepared to feel emotions as intense as…” Yes, it is! Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.

    I’m no expert, but doesn’t it make sense in a context of a situation where a danger exists for a long time? When someone gets stuck in a terrible situation (constant abuse, etc.), the desensitization might help to cope and not to be flooded with emotions that do not help to get out of situation anymore. If so, then the PTSD works as an ultimate “freeze” response as opposed to “fight or flight”, where a person turns off their emotions until the situation gets better. And then they are not able to get out of this state even when everything is over, the war has ended, the child grew up and does not need to freeze to stop hearing their parents’ argument anymore, insert any other cause of the disorder.

    I think it aligns with the symptoms of PTSD well enough?

    • alwhite says:

      The brain could be stuck in any of the three. Stuck in fight would be constant anger and explosive outbursts. Flight mode would be agoraphobia and hyper vigilance. Freeze mode is catatonia and dissociation.

    • The original Mr. X says:

      I’m no expert, but doesn’t it make sense in a context of a situation where a danger exists for a long time?

      I think that might be it, and it might also be relevant that a lot of the traumas our ancestral environment involved would have been relatively short-lived. Getting chased by a lion isn’t very fun, but it’s going to be over quite quickly, one way or the other; I don’t think stone-age man had to deal with something like being on the front line of WW1 getting continuously shelled for a week, and it’s plausible that our psyches would be poorly-adapted to deal with the latter kind of trauma as opposed to the former.

      • Cliff says:

        Maybe? What about slowly starving to death, your children slowly starving to death, outsiders driving you off your territory into marginal land, being enslaved, your kids dying repeatedly, your wife being stolen from you?

      • Jaskologist says:

        I’m not convinced that stone-age man is actually the relevant ancestral environment. We’ve been congregating in cities for a long time. And when I look at history, I see a lot of cities being besieged for long lengths of time. Now, that’s admittedly the sort of thing history likes to focus on, so maybe it’s not actually that common.

        But ancestors in China had to endure Mongol sieges that boiled their captives and then used the fat to hurl fire at the besieged. Eastern Europe also had to endure Mongol invasions (which killed about a quarter of the population of Hungary). The Israelites were beseiged and exiled from their lands multiple times, and I’m sure every city around the world has several such similar stories. All of that sounds really traumatic to me, and not at all short-lived.

    • JPNunez says:

      I feel Scott’s paragraph on evolution here is too hopeful of the abilities of evolution to make us into perfect machines, verging into magical thinking.

      There is a kilometer long list of things that evolution should reasonably have fixed yet we still are stuck with, and the brain is so complex that I am actually surprised the brain does not have _more_ weird failure modes. Particularly as the brain helped us escape a little from evolutionary pressures from other big predators, it stands to reason that it’d be the one where evolution would have less sway over.

  16. Don_Flamingo says:

    And why would the body be so confused by the right action being “hide” or “accept the pain and abuse” rather than “run” or “fight”? The safest action has been “hide” or “accept the pain and the abuse” in a pretty good fraction of traumatic events since humanity came down from the trees.

    That makes perfect sense to me.
    How is that confusing?
    People would rather die fighting than be constantly humiliated. Have you never experienced homicidal rage?
    It’s very difficult to deal with, without homicide as a realistic option.

    • Jliw says:

      “Why would evolution leave us with a brain that would rather fight or run than hide or accept abuse, if the latter is commonly a beneficial tactic?”

      “Because people would rather fight and die than hide or accept abuse!”

      That’s just restating the question, man.

      • There may be a useful distinction here between “doing X is in your interest” and “having characteristics that make you do X is in your interest,” the difference being the response of other people to knowing you have those characteristics.

        Consider bullying. It may well be the case that, in a particular situation, you are better off letting someone bigger than you hit you than trying to fight back. But the knowledge that you will fight back if attacked may be a reason not to attack you.

  17. Nav says:

    Alright Scott, I want to suggest a different frame for this, that aligns with another SSC hobbyhorse: let’s take a Fristonian view of PTSD.

    What is “trauma”, in a Fristonian sense (working off their REBUS paper)? Trauma writes a new set of priors at some level along the predictive hierarchy. This results in downstream effects. If you develop a new prior that hiding behind a tree and ignoring all sensory stimuli is the only way to guarantee survival, and then you take this “bad prior” out of the context of war, you’ll continue ignoring all sensory stimuli even if the experiences that caused the development of this prior disappear. This has been known for decades in the psychoanalytic literature as Neurosis (at least, according to some psychoanalytic thinkers).

    So if we make the assumption that Friston is correct about the etiology, let’s address some complaints:

    the first few studies on any technique – usually done in an atmosphere of frothy excitement, by the technique’s most fervent early adapters – are always highly positive. And later studies – done in an atmosphere of boredom, by large multi-center consortia – are almost always disappointing.

    If the goal of any treatment is to shift one’s priors, then of course treatment performed in a more exciting atmosphere will lead to more dramatic results. Excitement and novelty mean an atmosphere of (sacred?) significance, which has the best chance of allowing the patient to form a new set of priors. If the therapy is routine, then it’s unlikely to “push” the patient out of their trauma-induced, undesirable predictive position. How could we test this, though? How do you repeatedly generate an atmosphere of excitement, to permit the action of Science? These are interesting and difficult epistemological concerns, and I’d be interested in thoughts.

    Next complaint:

    Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.

    These events were potentially cyclical: a tribesman might experience war repeatedly throughout their lives. However, the current state of modern war leaves veterans returning, psychologically prepared for another go at war at any time, but without any real likelihood that they’ll be sent back out in the field. The result is that the developed priors become useless, rather than necessary preparation for the next conflict.

    We can also consider how ancient tribes may have handled “bad” prior formation by considering ritual experience. The sacred, the psychologically powerful, as a means of restoring a more “normal” psychic equilibrium. But I don’t want to get too much into pure speculative territory here without any real anthropological knowledge of how the tribes actually operated.

    My final critique was going to involve the idea of symptomatic vs etiological treatment, but I think that’s been addressed thoroughly in the other comments here. But I would like to hop on my personal hobbyhorse and comment that if we restrict etiology to a purely neurobiological realm, then we may lose out on significant opportunities to help people. It feels like the equivalent of only relying on genetics to diagnose physiological illnesses: you may well predict heart disease, but you’ll have no chance of diagnosing a viral infection. This is where having a deeper, systematic theory of mind comes in handy, and this is also where psychoanalytic theorizing is useful, because it operates at a layer above the neurobiological. Hopefully Friston and future research can unify the psychoanalytic sphere with the neurological sphere (the REBUS paper above already starts tackling some of Freud’s concepts of ego), producing a seamless hierarchy of mental reality as we have with body reality, but this is probably a few decades off.

    • Scott Alexander says:

      This review is a month or so old – I’ve since come around to some of what you’re saying after reading https://www.lesswrong.com/posts/i9xyZBS3qzA8nFXNQ/book-summary-unlocking-the-emotional-brain . Review of that impending.

      • Nav says:

        Word — a brief look at this LW post makes me suspect it’s the sort of synthesis I’ve been seeking; I should give it a read and note/write up whatever psychoanalytic parallels I can find. Looking forward to your review of it!

      • LeeBird says:

        Thank you for linking that post; it was quite illuminating. I’m inclined to agree with this explanation of the schema updating process. It tracks with what I’ve learned through logical, rational methods *and* with what I’ve learned through intuitive, emotional methods.

      • Nancy Lebovitz says:

        I’m looking forward to your review, especially since I find the premise of the book plausible but I feel somewhat emotionally swamped trying to read it.

        The first time I tried reading it, the print seemed too small to be comfortable. On the second whack, the print seemed smaller than average and with less space between the lines than usual, but it wasn’t a problem to read. This is the first time I’ve had that sort of problem with a book.

    • cuke says:

      A thought on this part: “If the goal of any treatment is to shift one’s priors, then of course treatment performed in a more exciting atmosphere will lead to more dramatic results…”

      There is a theory of family therapy that uses what it calls “ordeals” to produce change — ie, onerous, time-or-energy consuming tasks they have to undertake in service of change. Another family therapy method is to “prescribe the symptom” in which clients are asked to re-enact the problem sometimes in more dramatic fashion. Almost every therapy modality has some element of drama or excitement that disrupts the client’s default mode of responding. Koan’s are said to be used in Zen for similar purpose.

      Anyway, this is just to say that a lot of therapy technique is focused on shifting people’s priors, as you would say, and they use many varied and dramatic techniques to accomplish that. All of EMDR could be seen than way, as could IFS, much of Gestalt, a lot of expressive arts therapy, and so on.

      In treating people with PTSD, one has to be pretty careful about “exciting” — people often have multiple dysregulated rhythms and so need more quiet, more routine, more predictability so their nervous system can stand down a little.

      But I think your larger point here stands, which is that the therapist needs to bring energy, confidence, optimism to their work because the client arrives usually in a frustrated and dispirited state. And oftentimes it’s the therapist’s fresh hope in what feels like an old, stuck, tired situation that helps get things going. The therapist’s positive outlook can’t carry the whole process, but it makes for a good starting place. And just the experience of showing up for a new experience, whether talk therapy or medication, is a kind of ordeal that can lead someone to update their priors.

  18. TJ2001 says:

    I would absolutely believe that the brain is “Wired” to completely numb its body or do other “weird” things when severe mental/physical trauma happens. For example – it is well documented that the body is perfectly willing to “sacrifice” external parts (arms, legs, noses, etc) to survive… So if a person going cold and numb or “sort of crazy” results in being able to push 200% harder to achieve survival – then it makes sense…

    For example – kids who become “numb to abuse” can take incredible beatings and literally not feel it…. BUT – when those kids fight others – they often inflict far more serious damage on others (and their own bodies) because they don’t feel things like their own hands or feet breaking when they fight… They lose the internal sense of restraint that says “No, stop… Those are his ribs crunching…” All the normal personal restraint channels are shut off and they just go as hard as their bodies can possibly go with zero pain response…. And that is CONSIDERABLY harder than it can when it feels pain or emotion….

    So then…. It seems like the BIGGER question is “How do we get the brain to reactivate ‘Normal mode’ with feelings, emotions, and sensations?” …. Presumably – if the brain can turn it off – the brain can turn it back on given the correct signals that it should do so…. It’s just that somehow – it gets stuck in “Experience Trauma” mode….

    An interesting aside for Scott… The Jewish priesthood was forbidden to participate in war… Makes me wonder if this was partially to reduce the incidence of those men losing their emotions and sensation feeling like warriors would…

    • Don_Flamingo says:

      re: your lost-arm theory of those fight-happy kids
      I don’t think the people you describe are in “Experience Trauma”-mode at all.
      It’s just that having experienced trauma (and hopefully not too much head trauma, too), the brain adapted in some improvisational ways.
      If you’re not afraid of fighting hard anymore, then how could fighting still be trauma?
      Not sure if going back to “normal mode” is desirable or possible.
      Not possible, because how could neurological changes just revert to the default blueprint? The brain is firing and growing everywhere at once and doesn’t really stop.
      Not desirable, because punching and fighting hard is pretty great if you still need to defend yourself. Don’t think of them as broken, think of them as merely a little different (and a lot more dangerous).
      It’s more that they’ve got to learn restraint, peace and probably purpose.
      The internal mechanisms that they had before don’t work anymore, because they’re mismatched now.
      Trying to make them just like well-adjusted, carefree, happy people doesn’t sound too promising.
      Trying to make sure that they don’t get themselves or someone else killed, teaching them to put their aggression and fearlessness to productive use seems better.
      As a succesful (though fictional) example:
      Amos Burton in “The Expanse”
      Ur xabjf ur qbrfa’g ernyyl trg gur zbeny pbzcnff/rzcngul guvat, fb ur whfg bhgfbheprf gung gb Anbzv naq Ubyqra.
      Naq jura va qbhog ur whfg hfrf n pbhcyr unzsvfgrq urhevfgvpf yvxr: “Gur jnl V frr vg, gurer ner guerr xvaqf bs crbcyr va gur jbeyq: onq barf, barf lbh sbyybj, naq barf lbh arrq gb cebgrpg.”

    • AC Harper says:

      Talking of weird things, one of the family legends is that one of my ‘great great’ relatives returned from WW1 with “shell shock” and was never the same again. The legend says that he took all the family money and buried it in the nearby New Forest, never to be seen again.

      Co-incidentally a recent visit to a museum in the same are revealed that a significant number of Roman Coin Hoards have also been discovered in the New Forest. I’m not saying that the Romans suffered from ‘chariot shock’ but perhaps the nature of landscape lends itself…

  19. NovaByblos says:

    Regarding “patients’ different reactions to trauma” and “how much child abuse is there?” and “is PTSD a thing?” and “hasn’t trauma been around for eons?” and “what if we just don’t call it ‘child abuse’?”, is it possible that social/cultural factors/expectations play a really big role? (Maybe this is a naive/banal insight that everyone is already aware of, sorry, if so call me an idiot and ignore me!). I just remember some study (possibly debunked!) that people tend to have the reaction to alcohol (i.e. affect on inhibitions, etc…) that the culture around them expects alcohol to have. If we can modulate our behavioral reaction to the same chemical in such different ways, wouldn’t we also be able to do so with trauma, particularly since “how we respond to trauma” would be very important factor in our success in the small groups of likely-prone-to-frequent-trauma humans we evolved in? And even more, wouldn’t it also heavily affect how the wider society describes (or chooses not to) the effect of that trauma on individuals? I don’t mean to diminish the impact of PTSD or anything else in any way (not only just because “even if society just told me I should be scarred by X” is still a real and valid reason you might be traumatized by something!) but it does seem like it would be part of the explanation for a lot of this, including the “I read this book and it totally helped!” situations.

    • Aapje says:

      I think that you are exaggerating the effect of social/cultural factors. In WW I it was societally not acceptable to have shell shock, but people got it anyway.

    • LeeBird says:

      Before I respond in more detail, I’d like to be sure I understand you. Is the question you’re asking “if all children were abused and everyone thought it was normal, would the children still be traumatized?”

    • JohnBuridan says:

      You are referencing the Red Bull Vodka experiment where two groups of French young men were served Red Bull Vodkas, but one group did not actually have Red Bull in their Vodka. Thus demonstrating the psychological expectation of getting drunk can lead to drunk behavior.

      I don’t think there is a good way to extend this experiment’s results to PTSD. They don’t seem to map on right. But I take NovaByblos’ concern to be something similar to Sebastian Junger’s… We’ve recognized trauma for a few millenia now, but is our society somehow worse than previous ones at caring for the traumatized. Perhaps because a lower proportion of us have been traumatized the social sphere has changed, making the symptoms after trauma more pronounced/obvious?

  20. Doesntliketocomment says:

    On the subject of why people didn’t have PTSD in the past, I think it is a mistake to assume they didn’t. The unusual feature of the modern world is not that you can be exposed to trauma, it’s that you can be removed from it. In the modern world, a victim of rape may have trouble returning to normal life. In the ancient world if you are taken as a slave, then rape is a part of your “normal” life from now on. Anything that helps you navigate that is helpful, and in that sense it is not hard to see some aspects of PTSD as adaptive.

    Genetically, I feel this fits in with a lot of what’s being discussed today in terms of genetic predispositions that are triggered by outside events: Grow up in a peaceful village, run the peacetime program. Village is sacked and burnt, run the life is violence program. The only difference is that in our modern age violence.exe doesn’t work as well as a default mindset as it would have been in the past, so we want to find a way to turn off those behaviors as soon as they are triggered.

    • LeeBird says:

      The unusual feature of the modern world is not that you can be exposed to trauma, it’s that you can be removed from it.

      I mean this sincerely: what a lovely thought! Makes me appreciate existing here and now.

      • Aapje says:

        Unless the other commenter is right and we are forcing some people into trauma in ways that didn’t happen in the past (hello schools).

        The truth is probably in the middle.

        • LeeBird says:

          I’m speculating a bit here, but I believe the range (not necessarily the intensity) of possibly-traumatic experiences is narrower for neurotypical people than it is for neurodivergent people. There is a growing body of evidence that suggests *most* autistic people have c-PTSD as a result of:

          a) repeated negative social/emotional interactions
          b) behavioral therapy/modification
          c) being forced to endure painful/damaging stimuli
          d) being deprived of sufficient pleasurable/helpful stimuli
          e) any combination of the above

          While I do not claim to be autistic myself, I do vividly recall being held down at the age of 5, having a large cold silver spoon forced into my mouth, and being made to swallow liquid medicine, weeping and thrashing all the while. I did not eat with a spoon for 20 years afterwards, because the feeling of its shape in my mouth would cause me to have a panic attack.

          Was it objectively “abusive” for my caretakers to medicate me when I was ill? No. Did I subjectively experience this incident as traumatic? Clearly yes.

        • cuke says:

          Yes to what both you LeeBird and Aapje say here.

          The DSM criteria for PTSD focuses on direct exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.

          And yet I have a lot of clinical experience with people who have stories like yours about the spoon or other bad/scary/adverse experiences of childhood that were profoundly affecting a decade or more later. As well as people who describe a whole host of soul-crushing horrors happening in a school setting that don’t meet any of the above criteria but nonetheless are producing behavioral changes years later that get in the way of a person’s daily living. I suspect there is a portion of social anxiety that is really subclinical PTSD for having been treated pretty badly at one or more points in childhood.

          The other thing I see is clients who seem to have inherited multi-generational family histories of trauma. We could say it’s genetic, but without the science, we could also say grandmother’s terrifying immigration experience led her to raise her daughter in an environment of fear and hyper-vigilance and that daughter went on to raise another daughter who has no lived immigration adversity experience but grew up with her mother’s hypervigilance and continues to re-enact it in situations that, while stressful, are not life-threatening.

          Mark Epstein has written a book called The Trauma of Everyday Life that’s worth mentioning in this context.

          • Aapje says:

            I think that a ‘sense of safety’ is very important, yet not very well understood. It probably depends heavily on specific needs being satisfied and the mental model of the person, where those needs and that mental model can differ substantially per person. For some people, force feeding with a spoon was or would have been no big deal, while for others, it violates something essential.

            Note that we also seem to see that rape affects some people greatly, causing PTSD, while for others, it has no significant emotional impact (and for many, it has significant impact, but is not devastating).

            Note that there are all kinds of ‘life hacks’ that people employ to produce a sense of safety in children, although often merely because they notice that it makes children happy, not because they understand why. For example, pacifiers probably induce a sense of being with the mother and a feeling of food security. Swaddling produces a sensation of being held. Sleeping with a bear or other anthropomorphic toy produces a sense of being guarded and/or not alone. Etc.

            It probably works in part like a ledger, where things that positively produce a sense of safety, allow people to endure things that harm their sense of safety with much less or no ill effects (and this is why people who have a big lack of a sense of safety, are easily traumatized by things that seem like trifles to others).

            The DSM seems to miss the point in a variety of ways. They ignore the resilience that safety-inducing experiences can bring, that the impact of safety-reducing experiences depends on the resilience that people have and not merely on the extent to which the experience is (typically) safety-reducing, nor the differences between people’s needs.

            The DSM’s definition of PTSD seems tailored to reasonably well-calibrated people who experience a major safety-reducing event, treating the latter like a gunshot wound, even though so much evidence suggests that this is a bad way to think about it.

            A good metaphor may be a pugil joust, where life is like standing on a platform trying not to fall off, as you are getting hit by negative life experiences and trying to enjoy the positive parts of the experience. Excessive anxiety is then being unsure of or underestimating the size of the platform you are standing on. Even though stronger hits are more likely to knock you off, even a small push can knock you off, if you are already poorly balanced. A very well-balanced person can endure a very strong push and/or can deflect most of the hit. An apathetic/avoidant person has given up on trying to play the game. Etc.

            In this model, you can see how certain intervention can or can’t work. For example, encouraging an apathetic/avoidant person to climb back on the platform only works by itself if that person misjudges the risks of being on the platform and will have has sufficient confidence when being on that platform. If they do have life skills, but are afraid to use them, they need to be taught to trust their skills more. Yet if they lack those life skills, then teaching them to trust their skills will merely get them hurt due to unfounded confidence, so they need to be taught those skills.

          • LeeBird says:

            I shared the spoon story because it was the least dark example I had, and because I’ve been able to move past it. My actual reasons for having (suspected) clinical c-PTSD are not nearly so trivial…but those are stories for my therapist, haha!

            The other thing I see is clients who seem to have inherited multi-generational family histories of trauma.

            Anecdotally, this tracks. Part of my decision not to have children is that I simply don’t have enough hubris. Could an unbroken, centuries-long chain of complicated mother-daughter relationships by broken by ME? Doubtful.

    • andagain says:

      There is also the thought that in the days when being eaten by tigers was common, someone who had narrowly escaped being eaten would easily find someone else with a similar experience to talk to about it. It would be a lot harder to do that now.

      • Don_Flamingo says:

        Why would that even be traumatizing? That sounds like an adventure.
        When I picture that (assuming I didn’t take crippling injuries), I assume I’d start laughing manically, fall into the grass and sigh happily.

        • Mary says:

          Because you nearly got killed. This is extremely traumatic to most people

          • Anonymous` says:

            Haven’t you ever nearly been killed while driving? It’s traumatic for like five seconds and energizing after that.

          • Alsadius says:

            Anonymous: No, I get a bit freaked out by the thought of some of my near misses on the road, even years later. It’s not traumatic per se – it doesn’t interfere with my life, or even my driving – but it’s not even close to “energizing”.

        • Doesntliketocomment says:

          If I may be forgiven for making a couple of assumptions, I think this kind of speaks to what I’m saying about the different worlds of now and the past. The short version is you can picture yourself as removed from the danger once it’s over, where in the past the danger will never really be over.

          When you pictured almost being eaten by a tiger, you pictured the event: A furious action, terrifying in every degree in sight and sound-even smell, where your threadbare escape only serves to highlight your extreme good fortune. But in this you picture the event, not the context, and the context is what makes it truly damaging.

          Let me supply it: In the night, you were walking a few steps from your home to go to the bathroom. And importantly, this isn’t a freak event where a tiger got loose from the zoo, in your life there are tigers are out there every night. For our ancestors this kind of event isn’t a unique opportunity to look mortality in the face and walk away, as it might be for us; it is yet another demonstration of vulnerability, a mocking dress rehearsal of the final night when your luck runs out.

      • Nancy Lebovitz says:

        Peter Levine talks about discovering that wild animals deal with trauma by going off and shaking.

        I’m not and he isn’t saying it’s a complete cure for everything, but not having a chance to do it fairly soon could make trauma worse.

        • Aapje says:

          @Nancy Lebovitz

          That seems to just be the after-effect of adrenaline. I doubt that it has psychological benefits.

    • mtl1882 says:

      You explained this concept very well, and I think it likely plays a role. A lot of this is social–the fact that you can be removed from it means that you are likelier to experience being an outlier, on top of it being a non-workable strategy in your new environment. On top of that, modern society is very focused on a certain type of efficiency/stability/presentation and I think requires a larger degree of conformity in certain neurological senses even if it seems to allow more freedom. It constantly confronts people who have experienced these shifts with an obligation to be “normal” and happy, or to “fix” the problem of being otherwise. Even if people today are technically more “sensitive” about the issue, they’re also more likely to focus on it. Basically, modern society is focused on certain emotions and certain experiences in a way that ties them to identity and can make them defining. And we have few outlets for the aggressive, as you pointed out. This likely increases the awareness, suffering, and visibility of the issue. But it is so consistently present throughout human history in the last few hundred years that I assume it is built-in human reaction to trauma that has the potential to activate in a large number of people.

      • cuke says:

        This is really well said:

        “modern society is very focused on a certain type of efficiency/stability/presentation and I think requires a larger degree of conformity in certain neurological senses even if it seems to allow more freedom. It constantly confronts people who have experienced these shifts with an obligation to be “normal” and happy, or to “fix” the problem of being otherwise. Even if people today are technically more “sensitive” about the issue, they’re also more likely to focus on it. Basically, modern society is focused on certain emotions and certain experiences in a way that ties them to identity and can make them defining.”

        I feel like a lot of therapy is helping to build up people’s immunity to these social forces by helping them clarify who they are and giving them permission to feel less apologetic for the people they seem to be.

  21. arbitraryvalue says:

    …reading the book helped them figure out an indescribable mental motion they could take to resolve their trauma, and that after taking this mental motion their problems were gone.

    I’ve had a similar experience – years ago I used to have fairly frequent, intense bursts of guilt. For example, I could be walking along and then suddenly for no particular reason I would feel like I was the worst person in the world. It would come out of nowhere, almost like accidentally walking into a wall. And the guilt was always completely abstract, not connected to anything specific that I did or did not do.

    One day, I was thinking about my life and I realized that the guilt was because I was alive and my mother (who died when I was a child) was not. I would be eager to die in her place if I could. (Of course time travel appears to be impossible and the concept of “a life for a life” is from fairy tales and not how that sort of thing works in the real world, but the eagerness is genuine.) And with that, the guilt never came back. I still have issues, but I don’t have that issue anymore.

  22. Karl D says:

    Longtime lurker here, first-time comment here. FWIW.

    Scott’s discussion re immobilization triggered (pun intended) a question I never found a handle for in discussions with counselors of divers modalities: the potential difference when trauma or developmental disturbance is linked to what might be called a nothing rather than a something. That is, to an absence of something that “normally” or “typically” (or, more likely, “ideally” in our current way of express or implied judgment/expectation) would be something present.

    To put a finer point on it, while anger can be a useful and fruitful summoner of our energies to move through a developmental obstacle, anger seems harder to summon when it’s about “nothing” or an “absence” than when it’s about “something”. In the latter case, there’s a potentially clear object for anger (albeit not always accurate). In the former, the nebulous black hole yields either immobilization or finds a default substitute object – with the self being the most obvious alternative object. And then…tada!…the cluster of depressive/dysthymic possibilities.

    Decades of life have taught me that deeper understanding is not necessarily fruitful in good ways, but still over those years I’ve found others who’ve encountered what I’ve described above and I wonder if there are more fruitful ways of describing it to them. (I use fruitfulness rather than more utilitarian terms because in my experience it can resonate in broader/deeper ways than utilitarian terms typically do.)

    • Aapje says:

      Interestingly, this can also explain why people tend to scapegoat. It’s hard to get truly angry about a lack, unless you can blame someone or something for taking something from you.

      • Karl D says:

        Yes, that’s also true. The potential limiting factor for toggling that might be what would implicate the “superego” in Freudian terminology: whether or not the subject has deeply absorbed a sense of duty not to impose unjustly on others.

        Beyond, there are people who are quite aware that no *particular* other person necessarily “owes” them what is “normal/typical/ideal” (other than basic duties of nurture to a child as means and circumstance allow), and have a strong sense of boundaries about imposing any such expectation on others. As opposed to people who have a highly developed sense of personal entitlement.

        • Aapje says:

          there are people who are quite aware that no *particular* other person necessarily “owes” them what is “normal/typical/ideal”

          True, but a lack of this kind of ‘entitlement’ may be very unhealthy, just like an excess. The former probably makes for good abusees, causes loneliness and atomization, etc.

          Note that entitlement of being treated a certain way seems fairly orthogonal (or even negatively causally linked) to entitlement to impose on others, so you can have the seemingly contradictory situation where a person expects little from others, yet feels entitled to impose on others.

          In my society, there seems to be a substantial increase in anti-social behavior at the very same time where people seem to expect less from others and fear being assertive to people who impose on them. I don’t think that this fits a model with a single type of entitlement, but rather, that different kinds of entitlement exist, where people can be very entitled in some ways, but anti-entitled in other ways. The average can then be a moderate level of overall entitlement, although this is highly pathological, because it is an average of a pathologically low level of some kind(s) of entitlement and a pathologically high level of other kind(s) of entitlement.

          • Note that entitlement of being treated a certain way seems fairly orthogonal (or even negatively causally linked) to entitlement to impose on others

            At a slight tangent …

            Consider someone with a dietary restriction, self-imposed, medically imposed, or whatever. When attending a dinner provided by someone else, one possibility is to unobtrusively avoid whatever parts are not to be eaten and perhaps have a second meal when he gets home if that means missing large parts of the dinner. An alternative is to make a point of telling the host about the restrictions, with the clear implication that the host is supposed to either structure the meal accordingly or provide suitable alternatives for the guest.

            My impression is that, over the past fifty years, the latter has become much more common. That looks like a feeling of entitlement to being treated a certain way leading to imposition on others.

          • Viliam says:

            one possibility is to unobtrusively avoid whatever parts are not to be eaten

            This is only possible when “what is not to be eaten” is obvious, e.g. vegetarians. Not possible for e.g. gluten intolerant people — almost any food could contain flour, not necessarily visible.

          • LeeBird says:

            A pathological lack of self-interest makes one VERY popular, but at what cost?

          • Aapje says:

            @LeeBird

            I actually think that most people dislike it, even if they feel drawn to take advantage of it.

            Although I guess I might be debating your definition of ‘popular.’

    • cuke says:

      By this “when trauma or developmental disturbance is linked to what might be called a nothing rather than a something” — do you mean the experience of neglect by one’s caregivers or are you speaking of something else?

      I can’t tell if you’re saying it’s easier to find anger when a parent actively abused us, but when we simply failed to get what we need, what is there to be angry at? Is that it or something else?

      Apologies if I’m being obvious: children need active care and attention to adjust well and feel safe in the world. As humans, our needs go well beyond food and shelter. It’s the grownups who teach us emotional regulation. They can’t teach us that if they aren’t showing up in a genuine way for the relationship.

      I haven’t checked in on this in awhile, but my memory is that the research on childhood adversity shows that emotional neglect can be as devastating or more than physical abuse.

      • Aapje says:

        That’s how I see it. It is much easier to blame someone for doing harm to you, than blaming them for not being good to you, especially since the latter is often a lot more diffused and more demanding.

        Take sexuality. It’s much more obvious that someone harmed you by raping you, than that someone harmed you by not sleeping with you, even if we recognize that many people have immense sexual needs. If you are raped, you can easily blame the rapist; especially as the modern Western norm is that people never ‘ask for it.’ But if no one wants to sleep with you, who is to blame? Are they being unfair to you or are they fairly refusing a poor quid-pro-quo, where the burden is on you to improve your offer or to accept that you ask too much of others?

        To what extent do people have a duty to accept a poor quid-pro-quo to compensate for imbalances (like parents have a greater duty to children, because the latter are still more helpless), poor luck, etc vs people having to accept that they don’t get their needs met.

        Of course, parents are typically seen as having a fairly strong duty to actively provide positive experiences, yet that is typically insufficient, where people/kids also require positive experiences from their peers and others.

        my memory is that the research on childhood adversity shows that emotional neglect can be as devastating or more than physical abuse.

        This also explains why people, in particular children, can induce abuse by others to stop being neglected, when they have no ability to induce positive attention.

        • LeeBird says:

          I was not given adequate medical care and suffered from undiagnosed & untreated neurological issues for approximately 15 years. I am somewhat angry and resentful about the situation, but then again, I’m not sure that my parents had the knowledge or access to do any better.

          The best way I’ve found to handle it is 1) name and acknowledge these emotions when they come to me, 2) listen to them/recognize them as valid and rooted in lived experience, 3) allow them to be without feeling ashamed of them or trying to make them go away, 4) gently ask them if there is anything I can DO *here and now* to help them. 5) The answer to that question is always “no.” The emotions leave of their own accord after that.

  23. NLeseul says:

    The thing is, the hunter-gatherer environment was not likely one where people were coerced into staying in trauma-inducing situations once their flight instincts had been activated. A hunter-gatherer warrior is surrounded by loud and dangerous exploding things? She runs off and lives alone gathering nuts on the other side of the mountain. A hunter-gatherer child is being abused by tribal elders? He runs off and lives alone gathering nuts on the other side of the mountain. They didn’t have the coercive institutions that modern humans deal with that force them to stay in abusive environments. They didn’t get executed as deserters if they ran away from a war; they didn’t get picked up by child protection if they ran away from an abusive home.

    It’s just that everything changed when human population became dense enough that there wasn’t anywhere else to safely run away to, and human societies became complex and wealthy enough that self-sufficiency wasn’t a desirable option anymore anyway. So I don’t think it’s too surprising that the brain has failure modes that arise in these specific conditions that wouldn’t have come up in the hunter-gatherer environment.

    • andagain says:

      A hunter-gatherer warrior would be male. And anyone of any sex running away from the tribe would become vulnerable to almost any man they came across. And real hunter-gatherers have to cook what they hunt and gather, which typically means some woman cooking while some man hunts. Either would be hungry without the other. So no one is that free to run away from anyone else.

      Why does anyone think that the lives of hunter-gatherer humans beings was any more peaceful than that of hunter-gatherer animals?

    • Reasoner says:

      You can always run off to join the French Foreign Legion. (Not saying that will help with your trauma, just saying.)

  24. Alex M says:

    I sometimes wonder what kind of PTSD traumas could be caused by clumsy NSA surveillance and how such traumas could be counteracted. For example, say that you are a genius social scientist being spied upon by your government, which finds a way to hide cameras all over your house. Of course, being a government, they’re dumber than shit so you quickly realize what they’re up to. You say to the cameras “Hey, I don’t approve of this violation of my privacy. If you have something to say to me, come out and say it.” But of course they say nothing and try to gaslight you because admitting their espionage would not only reveal their own incompetence but also make them legally liable for violating your privacy. So there you are, with your government spying on your every move – in the bathroom, in the bedroom, EVERYWHERE. From a legal perspective, they’ve essentially turned you into a sex slave and are making non-consensual porn of you.

    Based on what Scott has written, this is the kind of thing that would cause severe PTSD, because you are being attacked and have no way of fighting back. But since fighting back and asserting control through personal agency and self-determination have been proven to mitigate the effects of PTSD, I wonder if it might be possible to mitigate the effects of such PTSD somewhat by fighting back in unconventional ways. For example, you could spread info-hazards by speaking directly to the hidden cameras and revealing very simple and elegant ways to conduct terrorist attacks that could kill millions of people in the U.S. Since you know that hostile governments doubtless have spies embedded in the NSA, these info-hazards will replicate very quickly, as it is in their best interests to spread that information to other enemies of the United States. In other words, once hostile governments realize the value of the information that you are giving the NSA, they will prioritize you in their espionage. Best of all, from a legal perspective you’re completely innocent of any culpability, since you’re entirely justified in speaking out loud to yourself in a situation where you have the reasonable expectation of privacy. In fact, if anybody carries the blame for those terrorist attacks occurring it is the NSA, since it is their own organization that is inadvertently spreading the info-hazards. If they weren’t watching you against your will, then this dangerous information wouldn’t be spreading. That would be a very interesting way to punish the NSA for their arrogance. And since dangerous secrets spread the most rapidly, the NSAs unlawful espionage and harassment campaign against you would eventually be discovered and become public. You could probably bring a very expensive lawsuit against them when your lawyer pointed out how they “basically turned you into a sex slave for over a year against your will.”

    It’s an interesting conceptual exercise in how to weaponize the Dark Arts of Rationality – a sort of modern-day vengeance parable. I might one day write a short story about it.

    • Aapje says:

      The Prisoner (1967) is a bit like your surveillance situation. Very interesting series all around.

      However, your idea of rationalist powers allowing you to escape seems a bit fanciful and full of hubris. The typical issue with terror plots seems less the ability to generate ideas, but more execution (and recruiting capable terrorists).

    • Scott Alexander says:

      I’m pretty skeptical of this hypothesis. Even ignoring the cPTSD stuff (which seems genuinely different), military PTSD seems really similar to “trapped in a burning building” PTSD or “family killed in a home invasion” PTSD. If you attribute military PTSD to shell shock, what happens to all those other things? Fake? A different disease which mysteriously shares the same triggers and symptoms?

      • sharper13 says:

        I happened to listen to Jocko Podcast 10 this morning, wherein a SEAL officer discusses a book from the perspective of a WWW II Marine grunt. One of the points he made was that the modern military PTSD belief is that it’s related to not just danger, but danger combined with a lack of control in not being able to do anything about it.

        So the same level of danger, but being able to move, maneuver, shoot back, etc… is under your control and doesn’t produce PTSD, but the equivalent level of danger while stuck unable to move in a hole in the ground waiting for a random piece of shrapnel from an artillery shell to kill you does produce PTSD.

        It’s easy for me to see the parallels between that and the “trapped in a burning building” PTSD or “family killed in a home invasion” PTSD, in that those seem to also imply a lack of control/inability to influence the result.

  25. Etoile says:

    This is a comment on the replication crisis. What makes it so frustrating is that, in all of the silly studies (like this Harvard one), there are almost certainly true things that are just hard to measure, or in which the studies neglect large societal patterns. The studies have very coarse outcome measures, like using mortality to evaluate a medical treatment or a medical system. Or studies that might be neglecting a large big-picture shift in the population, like students who might otherwise be good at math tasks not understanding the paragraph-long word problems. (Example from my childhood: an algebra state test asked a problem about “how many tickets does the club need to break even”. I didn’t know what “break even” meant, but figured it out from context…. but what if I hadn’t? It wasn’t a hard problem, but the test should not have been reading comprehension – just algebra.)

    Unfortunately, while studies and meta-analyses can help determine the truth, they don’t excuse us from thinking and trying to use intuition and common sense….. (Note: please don’t interpret this as an accusation that our host isn’t using common sense or something.) Which of course is still subject to biases and such. I don’t know of a solution to this problem.

    • Cliff says:

      in all of the silly studies (like this Harvard one), there are almost certainly true things that are just hard to measure, or in which the studies neglect large societal patterns

      Almost certainly?

  26. Mark Atwood says:

    I seem to inhabit a different world than van der Kolk. All of his patients showed bizarre and florid sequelae

    Given how many other famous psychology stories and books from the past century have collapsed under even gentle investigative journalism, maybe the reason is …

    … he made them up?

    • cuke says:

      I’m going to give the guy the benefit of the doubt just because he’s been in the field working almost entirely on trauma for over 40 years and often in residential settings where the level of severity is much greater.

      I’ve been in private practice for much less than that time and have no experience in residential facilities and a small but significant number of the clients I’ve met present with what I’d call “bizarre and florid sequelae” even though they are functioning marginally okay in their lives. I could see if I added more years to my career and put myself among a more severely-impacted population that that’s what I’d see.

      Of course, also possible he’s making stuff up.

    • Anonymous` says:

      People have got to start treating that as the default/null hypothesis.

  27. DarkTigger says:

    Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor concentration caused by child abuse. Bob has poor concentration caused by bad genes. Carol throws tantrums because child abuse. Dan throws tantrums because bad genes. The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder?

    To me this sounds like we need more classifications, not less, right?
    I mean having a cough because of pneumoconiosis, or because of an chronic infection, should be treated differently, also.

    • Ketil says:

      To me this sounds like we need more classifications, not less, right?

      Why? How would it change therapy for Alice and Carol in contrast to the treatment for Bob and Dan? I get that it is convenient for Carol to blame her bad behavior on an external factor, but I don’t think it helps straightening her out. Maybe if I get a psychoanalyst to plant false memories of child abuse in Dan, the cure would then work for him too?

      • DarkTigger says:

        Because both Alice and Carol reacted differently to the child abuse, which suggest to me that both of them have diffrent conditions.
        Just as both Bob and Dan probably have different sets of “bad genes”.

  28. Mark Atwood says:

    Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology”…the textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis, and allows for a better adjustment to the external world.”

    I can’t help but wonder about the authors and reviewers and readers and professors of those textbooks.

    And how they treated their daughters.

    This is closely related to “Freud discovered that a lot of his upper middle class Jewish Viennese women patients had been molested by their fathers and uncles. When he announced this, he was told this was unthinkable, unspeakable, and unprintable. So he caved in for the sake of reputation and money, and instead faked up a fake theory that all these women actually secretly wished that they had been molested, and faked up stories that they had been.”

  29. Fractalotl says:

    A colorful typo: “colunteering for prats” in the Shakespeare section. (Intended to be “volunteering for parts”)

  30. Solra Bizna says:

    The sections on the dangers of child abuse were a good knock-down of some hypothetical “child abuse isn’t really that bad” position, but I don’t know anyone who holds that position …

    I know of more than a few. I once had a really bitter argument with such a person. He attacked someone on Twitter for opening up about their trauma and its effect on their life. His stance boiled down to: “Practically everyone was ‘abused’ as a child. I was ‘abused’ and I turned out fine. Just shut up about it and stop being such an attention whore.” I tried to explain to him why his approach was harmful and why “everyone” was suddenly “hating on” him. I didn’t manage to get through to him at all, and got badly retraumatized in the process of trying. Fun stuff. (I’ve seen that exact dynamic play out probably half a dozen times, even though I normally shun social media. This time I only tried to engage because I knew the person.)

    • LeeBird says:

      His behavior demonstrates that he did not turn out just fine, though he will likely never accept that. :/

      • Solra Bizna says:

        His behavior demonstrates that he did not turn out just fine, though he will likely never accept that. :/

        I agree. It was one of those cases where a serious problem is obvious to everyone except its sufferer.

      • benwave says:

        His mentally labeling of himself as fine, thus justifying the abuse, is almost certainly his coping mechanism. Challenging that was always going to be extremely threatening to him.

  31. J.D. Sockinger says:

    I’d be interested to know what people think about this blog post, which argues that PTSD is “A very modern trauma“. Unfortunately, the papers he cites are locked behind paywalls, and I don’t have access to them.

    • mtl1882 says:

      A study just published in the Journal of Anxiety Disorders looked at the extensive medical records for soldiers in the American Civil War, whose mortality rate was about 50-80 greater than modern soldiers fighting in Iraq and Afghanistan.

      In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.

      I read a lot of historical documents from this time, and it doesn’t come up as much as I’d expect, but they also weren’t usually asked directly about it. Crucially, that mortality statistic means that way fewer people survived combat at that time! Most of them weren’t around to have flashbacks. On top of that, not all veterans are affected–it isn’t a number thing, or something that directly correlates with the amount of death going on. Virtually everyone saw death on a regular basis, given the state of medicine at that time, so that alone was not shocking. Most soldiers died of disease or infection, not from direct combat, and the nature of warfare is such that the terror may not have been more intense or frequent in most situations. I’m sure it was plenty terrifying enough in some–“Worst Seat in the House,” about Col. Henry Rathbone, who survived the Battle of the Crater (particularly traumatic) and witnessed the shooting of Lincoln from a few feet away, argues he had PTSD.

      Whether or not the author is correct, the book provides a lot of context that is useful to this debate. Rathbone became increasingly disturbed and eventually murdered his wife. A lot of witnesses to the assassination, including combat veterans, described intrusive thoughts and nightmares related to it–something about that event seemed to be destabilizing in a way that battle had not been for them. It occurred at the time lilacs bloom, as Whitman noted in his famous poem. Charles Sabin Taft was a *surgeon* who witnessed the shooting and the aftermath, and his sister later wrote, “as long as Charlie Taft lived the scent of lilacs would turn him sick and faint, as it brought back the black horror of that dreadful night.” He’d spent the last few years hacking limbs off without anesthesia, but that made him sick! From that description, we don’t know if it reached the level of a flashback or intrusive thought–it could be a dramatic touch, but that was the sort of thing they were generally euphemistic about. A young military doctor who was unable to stop thinking about it was told by his superiors to block all of it out of his mind, and he focused on doing so for decades before speaking out. That advice seems to have been prevalent, so they may have been primed to block out intrusive thoughts instead of process them. If you cope by shutting down or refusing to talk, and society decides it wants to focus on glorifying the war instead of dealing with it, no one will know about your intrusive thoughts, but that may well be what is causing a noticeable mental decline. We’re trained to talk things out more, and talk therapy means you have a lot more of a record to work with.

      I wish I could see the locked paper, but I have a feeling the guy is taking the absence of data for the absence of trauma. It was easy to lose track of people back then. It does seem like actual flashbacks came up less–but are those super prevalent now, or are they just the stereotype people have of what it is “like” to have PTSD–for me, the first thing that comes to mind is hypervigilance, which I assume is more common. I also wonder if living in a televisual age makes full flashbacks more prevalent–we’re used to inhabiting multiple realities at once, in some sense, and to experiencing things vividly and vicariously.

      • mtl1882 says:

        I tried to edit this and missed the window, so I lost my post. This book looks interesting. If I understand this correctly, between 1980 and the last decade, the way the DSM defines PTSD has shifted in favor of emphasizing the memory part of it, along with emotional outbursts and depression, over the hyper-vigilance and numbing aspects. I think this reflects cultural preoccupations that will mean less of a match up over time.

  32. jooyous says:

    I think the thing you’re forgetting is that we evolved under group selection and we came down pretty hard on the cooperative, pro-social strategy. So maybe the mechanism by which we became good at cooperating is that we’re born with hard-wired fictions like “you are a valuable part of your community” and “you can trust people”. And, since there is also an evolutionary advantage to free-riding on your community’s resources (in a way that no one notices), maybe PTSD is the mechanism by which abuse victims were able to maintain community cohesion and keep quiet about their abuse, while internally not being able to reconcile the pre-wired fictions they were born with?

  33. graehl says:

    FWIW, I’m aware of 6-13 year old sexual child abuse by biological fathers (thankfully none related to me) in 1 of 50 white families I’ve known reasonably well. The general rate could be 10x higher or lower but I doubt it.

  34. viVI_IViv says:

    Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor concentration caused by child abuse. Bob has poor concentration caused by bad genes. Carol throws tantrums because child abuse. Dan throws tantrums because bad genes. The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder? Seems sketchy.

    Isn’t this how medicine works outside psychiatry? Alice and Bob both have respiratory problems, Alice has been infected by mycobacterium tuberculosis, Bob has a mutation of the CFTR gene. You diagnose Alice with Tuberculosis and Bob with Cystic fibrosis, you don’t diagnose both with Respiratory Disorder.

    Why does PTSD exist? “The brain isn’t prepared to feel emotions as intense as…” Yes it is! Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.

    I suppose that the typical traumas you get in modern conflicts are different than those a hunter-gatherer would experience. If you are being chased by lions or enemy spearmen, the best responses in most cases is either fight back or run away. Indeed the “fight-or-flight” response to acute stress is common to many mammals, especially predators and large preys. Some small prey animals tend to freeze and play dead instead, but this typically doesn’t occur to humans.

    Now, imagine you are in the middle of a WW1-to-Vietman era battle, bullets whizzing past your ears, shells landing around you, smoke and dust everywhere, the adrenaline flowing in your veins is telling you to either charge gung-ho or turn back and run for your life, but you know that both options would get you instakilled, so you have to suppress your instincts, take cover, move slowly and cautiously, infer the enemy position and movements from the scarce sensory information you have and game-theoretical reasoning about their strategy, and so on. And yet you realize that even if you play according to the perfect soldier training manual, you still have a good chance of getting killed, who lives and who dies will mostly depend on a combination of strategic factors you have no control over and dumb luck. Probably the automatic fight-or-flight response suppresses the helplessness: the cornered mouse lashes back at the cat, if instead you start to think rationally about how likely you are to die if you do X, Y or Z, then you can’t help but notice how powerless you actually are.

    I conjecture that the voluntary suppression of the fight-or-flight response and realization of helplessness can knock the weights of your neural network into a sub-optimal local minimum (to use a deep learning analogy), where your emotions are suppressed and you underestimate your ability to control the situations you are in.

  35. roflc0ptic says:

    There’s an interesting nexus between the buddhist path and the takeaway that healing trauma is often aided by getting in touch with one’s body. Breath meditation and body scan meditations are sort of the foundational tools that buddhism uses to get you in touch with what’s happening in your head – “wisdom” follows later, after you’ve learned to calm down.

    Pet theories follow:

    TBKtS left me thinking that trauma is both adaptive and ubiquitous – for victims of e.g. human trafficking, stuff like extreme dissociation seems plausibly beneficial. It’s also my guess that trauma is “nothing special”, in the sense that the anxiety that keeps you from mentioning politics when Uncle Ricky is over at thanksgiving is the same mechanism at play in catatonic PTSD, except it’s turned up to 11 in the latter case.

    The “problem” with trauma responses is that the triggers summon an overwhelmingly intense context that drives you towards one pattern, e.g. shutting down, or shouting at Uncle Ricky for being a murderist. Turning up the rheostat on your physical bodily experience you entertain the triggering stimuli while maintaining a safer context, namely a physical reality where there’s no threat present. Alternatively, EMDR and ART function to “break” the context that gets brought up. As far as I can tell with ART, you’re essentially implanting false memories. Voila, context obliterated, trauma response ameliorated.

    So then, grounded in the idea of grounding yourself in physical experience, the primary value prop for mediation that I see is giving people tools for dealing with moderate amounts of trauma. If we’re in the business of reducing suffering, I suspect the rest of it (what is enlightenment? is meditation unique?) is kind of a sideshow.

    • LeeBird says:

      It requires a whole toolkit to repair one’s trauma, in my experience. The process is something like inheriting a grand ruin of a house from your parents, which you must renovate almost entirely on your own, because you cannot live elsewhere.

  36. The sections with the symptomatology and neurobiology of PTSD were helpful in exploring the boundaries of the syndrome, but didn’t make me feel like I really understood what was going on.

    Many who work with trauma, professionals and survivors, found Stephen Porges’ Polyvagal Theory helpful in wrapping their heads around a neurobiological cause. Polyvagal Theory also describes cures, the power of human connection to release badly charged memories which lock people into a Fight, Flight, or Freeze response. Sometimes people fall into the Freeze response (low engagement) simply to conserve energy after their sympathetic nervous system spent too much time set at Fight or Flight. I say all this as a survivor. But I’d love to hear the SSC communities take on Polyvagal therapies.

  37. jerryb0222 says:

    Several good comments on this post. A few thoughts:

    As Scott mentions in his reference to his “Different Worlds” post it seem many of Scott’s patients are very intellectualized. In the Different Worlds post Scott mentions that he tends to attract patients who are very much “in their head” and not the more emotional, creative, primary process/fantasy types (i.e. people who would be drawn to books like Body Knows the Score.)

    On to genetics.

    When TBKtS was published in 2014, we already know with certainty that schizophrenia was about 80% genetic, and at least 15 genes had been identified as especially likely to be involved; today we know hundreds and can even make primitive polygenic predictors

    While I do not view Wikipedia as a definitive source, if you read the section in the Causes of Schizophrenia page just because schizophrenia is 80 % genetic does not mean people who appear to carry “schizophrenia genes”become schizophrenic. There is a gene x environment interaction. Also, recently I have been reading Dante Ciccheti’s Developmental Psychopathology volumes and I recall in the volume on Developmental Neuroscience the genetic component of schizophrenia was closer to 50%. Also, they refer to twin studies showing a significant environmental component in schizophrenia.

    That being said, I agree that Van Der Kolk did not give enough focus on genetic influences. But not everything can be reduced to genes. Another very popular book that seems similar to TBKTS is Eugene Gendlin’s work on focusing and the felt sense.

    Lastly, when I have tried to check out the Body Knows the Score from my local library it is usually checked out which tells me that it is very popular and the books themes resonate with people. On Amazon the book has 89% five star ratings which I rarely see on Amazon.

    IMO, overall I think Scott is being too focused on the book’s shortcomings in regards to PTSD and it’s lack of attention to genetics. As the “Different World’s” post mentions Scott’s leanings tend to be the more rationalistic views. However, it was nice to see the Update with Scott being a bit more open minded. The overall message of the book for me was being aware of the “somatic’ experiencing of people’s trauma, feelings, etc. Many people deny or repress their traumas/abuse but certain parts of their body may “hold” the trauma.

    • Null42 says:

      Interesting. Yeah, I could see psychiatrists specializing by patient type–seems like it would benefit everyone. A ‘geek psychiatrist’ would be more able to provide coping strategies dealing with things like social anxiety, and possibly autism-adjacent sensory issues, and so on.

  38. andagain says:

    “So the first step in raising awareness of PTSD was – amazingly – convincing the US military that some people might get PTSD from combat.”

    What term did the military use before? A WW1 airman might be diagnosed with Flying Sickness D, rather than PTSD, but does that mean anything except the RFC in 1918 used a different acronym to the one he was trying to sell a few decades later?

    (Winged Victory, for example, is a novel almost entirely about a pilot with what would now be PTSD, but was written by a veteran in the 1920s. No other character thinks the central character in any way odd or unusual.)

    • Janet says:

      As I noted above: there were a string of terms to describe this same basic phenomenon, as far back as we have records. “PTSD” today; in Vietnam “Gross Stress Disorder” and “Adjustment Disorder”; in Korea and WWII “Combat Stress” or “Combat Fatigue” or “Battle Fatigue”; in WWI “Shell Shock”; in the Civil War, “Soldier’s Heart” or “DaCosta Syndrome”; and before that, “Nostalgia”.

      One issue with the VA, specifically, is, that it is required to use a Code of Federal Regulations to evaluate medical conditions; this is subject to federal laws, court cases, administrative requirements, and more, and it takes years and years to make any change at all. So, many of their decisions are known, by everyone concerned, to be nonsensical– but they can’t take a sensible approach under the law or regulation. (They also hire some, shall we say, less-than-they-ought-to-be personnel… but that’s a separate issue, don’t get me started.) And nobody is particularly interested in getting something that will cost money, added to the CFR. The bias is always going to be against expanding the definition of disability; these usually have to be done directly with legislation from Congress (as, e.g. Agent Orange exposure).

      My own theory on this is, previously, our society was a much simpler place, and so somebody who was knocked off their “peak” but was still mostly functional, could still get a job, a house, etc. and was just expected to get on with their lives. Veterans would get together with other veterans, such as with the VFW or American Legion, for an understanding group of friends (and an equivalent group for their wives) to talk to. Such as my father in law, who pretty much came home from Korea and moved on with his life– although he developed an alcohol problem, had a variety of physical impairments, and would wake up crying periodically until the day he died. Or the man my husband always called, “Poor Mr. Brauner”, who made it through Bataan and the Japanese POW camps, but lived by himself in a shack just off the highway, never married or held a job beyond an unskilled laborer, had a very limited tolerance for being around people, hard drinker (maybe alcoholic), died in his 50s… but was already an old man by then.

      Today, though, there’s few (if any) decent jobs for a guy who will periodically show up exhausted and maybe hung over at work, or get unreasonably angry and co-workers for no apparent reason sometimes. Nobody to keep a general eye on Poor Mr. Brauner, make sure he’s at least got a landscaping job during the week and is up and around on the weekends. So we try to fill the gap with a check from Uncle Sam, and a disability rating… and it’s worse by a long shot, but that’s what we’re doing.

      • andagain says:

        I’d like to see some evidence that shipyards, mines, textile mills and so on really are so much more welcoming environments for someone suffering from a traumatic stress disorder. It doesn’t seem like the sort of thing you should expect. Yet those are the kinds of workplaces that have become rarer.

        • mtl1882 says:

          I don’t think they have to be more welcoming overall environments for this to hold true. They could even be more likely to trigger strong reactions on occasion–like from loud noises that sound like gunfire. The key thing is that workplaces today have virtually no tolerance for “difficult” people—it reminds me of Scott writing about the patient who randomly shouted “grahh” at times but was totally capable of doing the work required by many jobs. However, no one would hire him, because that disturbs other people, and they can easily get someone who does not do that. Most positions nowadays are somewhat “customer-facing” and very focused on presentation, even if they are simple and low-paying. And, people move around a lot–when everyone worked at the same company for decades, doing manual work without much interaction with the general public, a man like the patient described could get a job at his brother’s factory, where his quirks were known and everyone had gotten used to it. Even someone who is just cranky and awkward may alienate his co-workers quickly enough to cause problems in an office environment–it only takes occasional instability to cause a problem. A low-level guy who is moving things around at a shipyard can to some extent have whatever attitude he wants as long as he moves the items correctly. Maybe eventually he has an outburst and is fired, but he doesn’t have to emotionally regulate himself and look good in front of his co-workers every second of the day, or pass an interview based on soft skills.

      • sourcreamus says:

        I think this is an important point. Not that society is so much more complex, but that the tolerance for alcoholics is so much less today. The three martini lunch used to not be a big deal but would get almost anyone fired today. For blue collar people it would be very common on paydays for wives to wait for their husbands at the factory gate so they could some money for groceries before it was all spent at the bar.

        Alcohol used to be the go to treatment for PTSD and it was just accepted.

  39. Garrett says:

    I’m not sure what to think of this or how much I should revise the negative opinion of this book which I formed before this event.

    How much of the value that these and other similar books provide is simply by providing people a language or frame of reference to communicate their expression to others? Internal emotional states are frequently hard to describe (praise be the poets who can do so!) and having any shared language or experience is a way to connect and share that experience. Perhaps the trauma experienced is further worsened or complicated by feeling alone and/or an inability to communicate their experience to others.

    • LeeBird says:

      That is certainly at least some of its value. I believed that no one thought or felt the way I did, until I read what other folks with C-PTSD said about their thoughts and feelings. The details of trauma/abuse differ from one person to the next, but the strategies for coping/healing have broad application.

  40. Darkhold says:

    I found the descriptions of PTSD numbness really striking because they’re the complete opposite of my recent experience.

    I don’t have PTSD but I do practice detachment, I think because I experienced a lot of social disappointment as a child. But over the past few weeks, I’ve been practicing getting more in-touch with my senses. Now, as I get more attuned to how I feel and what’s going on around me, I feel more alive but also more content and confident.

    The practice of being more attuned with my senses is coupled with ascribing more meaning to my life. Like I have to justify the increased sensitivity because it has a cost in psychic discomfort. So it’s usually very unpleasant in and of itself but has the secondary effect of elevating how good I feel about myself.

  41. Darwin says:

    “Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this”

    Any reason to think it hasn’t?

    PTSD is subjectively unpleasant, but do people with PTSD have fewer successful offspring? In hunter-gatherer tribes?

  42. Reasoner says:

    In these more cynical days, we know that the first few studies on any technique – usually done in an atmosphere of frothy excitement, by the technique’s most fervent early adapters – are always highly positive. And later studies – done in an atmosphere of boredom, by large multi-center consortia – are almost always disappointing.

    What if having an excited therapist is more important than the treatment methodology they’re using? Maybe what matters is that you’re treated by an individual that really cares about you and really wants you to get better (if only so they can get the result they want for their study) instead of a dreary, uninspired medical bureaucracy.

    • LeeBird says:

      According to the research I’ve read, EMDR appears to work regardless of how competent or engaging the therapist is, and I would hazard a guess that many other physical/mechanical therapies would be the same.

      However, talk-based therapy is very much about the relationship. My former therapist (who I only stopped seeing because I moved away) is a woman in her late 20’s, immersed in the same sort of sociocultural environment I myself exist in, and it was delightful to work with her because there were so many things I didn’t have to explain. I could say “I haven’t posted a selfie in six months” and she understood what that signified instantly. She knew the difference between ironic, memetic suicidal ideation vs. a genuine intent to self-harm. Most importantly, she was down with the LGBTQ community, didn’t lecture me about my recreational drug use, and asked precisely one question about my ethically non-monogamous relationship structure (“Does everyone know about each other and is everyone cool with this?” “Yes.” “Good.”) A therapist like that is worth their weight in gold.

  43. philwelch says:

    Two points.

    First, there’s a fine distinction between “child sexual abuse committed by a legal parent/guardian” and “incest” that might look very significant based on the statistics for the incidence of child sexual abuse as committed by stepparents vs. biological parents.

    Second, as for combat PTSD in particular, there is a lot about modern combat that differs from the kind of stress that would be experienced in the premodern era that we are still genetically adapted for. Ancient combat wasn’t filled with loud gunfire and explosives at the very least, and it’s likely that ancient warriors also got better sleep.

    Perhaps most importantly, many warriors today are specifically trained to overcome the natural human inhibition against killing. Compared to the World Wars where surprisingly few men in combat actually fired their weapons at the enemy, let alone made an honest and deliberate attempt to kill them outside of the most desperate of circumstances, modern ground forces are thoroughly trained to kill and hence are more likely to have the traumatic experience of having knowingly killed people. (This theory also seemingly tracks backwards into history: in the era of bayonet charges, for instance, there were surprisingly few combat deaths by bayonet.)

    • Nancy Lebovitz says:

      There’s an essay by David Drake about how war has gotten worse for soldiers. More continuous (low tech meant stopping for night, and also for planting and harvest seasons), louder, and more random.

      • The original Mr. X says:

        More continuous (low tech meant stopping for night, and also for planting and harvest seasons),

        Reminds me of the theory that the ancient Roman practice of fortifying their camps each night was as much about psychology as practical defence. Knowing that there was a defensive barrier between them and the enemy, even something as simple as a ditch and row of pales, made it easier for soldiers to “switch off” when they weren’t on duty.

        • cuke says:

          That’s so interesting, Mr. X! Might you happen to have a citation for that bit of Roman history/theory?

          It makes a potentially wonderful metaphor for wondering what set of even symbolic practices one can employ that enable the nervous system to “switch off” when the world feels like a scary place.

          • The original Mr. X says:

            Unfortunately, it was so long ago that I can’t really remember. It might have been Goldsworthy’s Complete Roman Army, but I couldn’t swear to it.

  44. clipmaker says:

    Going beyond escape vs no-escape, PTSD (my impression) follows an “extinction burst” and it can take quite a while for that to emerge. Learned helplessness was another term that I’ve seen. That can happen with grief and loss, e.g. Bonnie Green (2000), Traumatic Loss: Conceptual and Empirical Links Between Trauma and Bereavement, Journal of Personal and Interpersonal Loss: International Perspectives on Stress & Coping, 5:1, 1-17, http://www.tandfonline.com/loi/upil19

    “Actually, data gathered in a number of studies indicate that people who have experienced one traumatic event are likely to have experienced multiple events, making it difficult to link symptoms with a particular incident” (from above article). That fits in with predisposition to PTSD having a genetic component (https://health.ucsd.edu/news/releases/Pages/2019-10-08-study-reveals-ptsd-has-strong-genetic-component.aspx)

    I’ve been wanting to read Allan Schore’s book “The Science of the Art of Psychotherapy” (2012) Schore has written a lot about disorders of affect regulation, which would possibly encompass PTSD. “Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development” (1994; Routledge reprint 2015) is a famous book of his that I also would like to read someday.

    He has an article collection “The Allan Schore Reader” (Eva Rass, ed.) which looks interesting. Scott A, you might want to look at his stuff since I think his approach might be what you were looking for in van der Kolk’s book.

    “Fear of predators causes PTSD-like changes in brains of wild animals” talks about PTSD in the brain: https://www.sciencedaily.com/releases/2019/08/190807112939.htm

    Military PTSD is in fact often caused by blast injuries: https://www.nytimes.com/2016/06/12/magazine/what-if-ptsd-is-more-physical-than-psychological.html

    One of the markers of PTSD is supposed to be nightmares. Has anyone monitored stress hormones (cortisol in saliva or whatever) of a PTSD sufferer during the person’s REM sleep, and compared the level to that of non-sufferers?

    • thetitaniumdragon says:

      I wonder if the blast injuries thing is actually misdiagnosed CTE. Some of CTE and PTSD’s symptoms can be similar:

      * Confusion.

      * Personality changes (including depression and suicidal thoughts).

      * Erratic behavior (including aggression).

      * Difficulty sleeping

      CTE doesn’t involve flashbacks whereas PTSD does, but I could see someone who suffers from many of those symptoms being misdiagnosed.

  45. Quixote says:

    Two quick notes

    – see your reading history backwards post. The fact that it’s obvious abuse is bad now does not mean that it always was obvious.

    – this book may not be aimed at you. I got the impression that this book was aimed at people with ptsd and was meant to be read by people who had the condition, not people treating it. And it’s worth noting that your one anecdote of giving the book to someone with the condition was highly successful.

  46. mtl1882 says:

    “Railway spine” was a disorder that started appearing in victims of train wrecks in the early 1800s–the first mass casualty incidents to occur with regularity, pretty much. It sounds just like PTSD, and that is now what it is believed to have been. Doctors thought that whiplash from the accident deranged the molecules in the spine…it wasn’t a *bad* guess, all things considered. Then they noticed its prevalence during the Civil War, among people who hadn’t been in railway accidents but had seen combat.

    Van der Kolk describes a study on stereoagnosia in PTSD patients: if blindfolded and given a small object (like a key), they are unable to recognize it by feel, even though this task is easy for healthy people.

    While I’ve been unable to trace it to any event or trauma, I’ve for the last few years had symptoms that seem to correlate well with PTSD. One of them, though I had not been able to connect it to a larger theory, was that suddenly I was unable to rummage around in my purse to find items without looking. Like, my hand just does not perceive what I am feeling, and it causes this bizarre sense of panic and impossibility, even if the item should be pretty easy to recognize and obtain. I have no idea how to explain the phenomenon, but this was interesting to read.

    the absolute firewall between bodily sensation and conscious processing.

    This is an accurate description of what I experience. If I attempt to think about my situation and get on track, it seems to immediately shut down my sense of “being,” and therefore the thoughts don’t “take.” They don’t internalize. Because of this, it feels like no progress is made, like I’m trying to write but there’s no sensation of making an indent on the paper. It is bizarre. The “mental motion” or interrupted motion therapy idea has always appealed to me, because that is what it feels like–missing the off-ramp, even if you are aware there is one. It’s like the reaction process doesn’t complete. But I know it also sounds mystical and may well be totally wrong.

    I’m pretty sure people noticed the similarities in psychological issues between some veterans and some sexual abuse victims early on–I thought I read that Freud pointed that out at one point, but sort of dodged the issue? I was reading letters from the 1860s or 1870s in which a woman noted that she had a friend who was eccentric and emotionally hardened, and she commented that the friends seemed “demoralized” like many of the Civil War veterans. I don’t find it hard to believe that there is a certain reaction caused by that sort of trauma (somewhat prolonged vulnerability in a situation where fleeing isn’t an option, possibly combined with complex social factors or a confused feeling in hindsight that you *should* have somehow done something different) that can look similar to symptoms caused by “bad genes” or a number of other problems, but still have a different underlying dynamic that would be beneficial to recognize and treat specifically. Of course, it it may also just be an false explanation that sounds good, and it is important to figure that out. But I don’t see why it wouldn’t be a possible way to categorize. Also, some people could genetically have issues with some of the emotional regulation that becomes dysfunctional after trauma–it can be relevant without being exclusive.

  47. clipmaker says:

    There was a huge drama in the Freud scholarship world about [Freud’s seduction theory](https://en.wikipedia.org/wiki/Freud%27s_seduction_theory) a few decades ago. Jeffrey Moussasief Masson was the director of the Freud Archive, found and published some evidence about it, and had an incredibly acrimonious split with the Archive, and with Sigmund Freud’s granddaughter Anna Freud who had first appointed Masson to the gig. I didn’t pay much attention to the details but it got some news coverage while it was going on.

  48. Mike-SMO says:

    Whole bunch of “Just So” stories.

    As for military rotations, mentioned above, I am told that it is a statisticalmatter. Bringing in an entirely new unit means that a bunch of people are now in an environment where they don’t know who among the “locals” is friendly and what things or places are dangerous. Brining in individuals allows for some “on the job” training although there are personal stresses since the FNG [F___ing New Guy] is mostly likely to be killed or to do something that gets his fellows killed.

    I am very sympathetic to the APA as to diagnosing symptoms and “disorders” rather than “causes”. It is next to impossible to disentangle genetics and interpersonal relationships for a particular patient. The patient may say, “I was abused”, while the parents may say, “No, He/She was always weird, just like his/her cousins”.

    Well, the therapist has the lay of the land, beyond that is the game of divorce court; “He said, She said”. The therapist has becomes effectively burdened with a badge and handcuffs which may make both the family and patient defensive and uncommunicative. If the parents are proved to be abusive, then the patient gets the burder of “betrayal”. Alternatively, the patient’s mental state provides “evidence” of criminal behavior by innocent parents.

    The focus on the sexual aspect of “abuse” is a traditional fantasy. The most severe “abuse” that I am aware of included erratic and, in my view, “brutal” punishment that included isolation in dark rooms or basements. I suspect that there would have been no sex/incest involved but I sure would expect some emotional or behavioral consequences in the “survivors”.

    The potential contributions to maladaptive behavior is a concern in therapy. Weird families have weird children and such folks may respond differently to various forms of therapy. That real consideration is easily lost in the current non-therapeutic confrontation of ideologies and politics. Did the patient’s mal-adaptive behavior come from a childhood in the “ghetto” or did “their” common mal-adaptive behavior cause the “ghetto”? I think that it is likely that a child that grew up in South Chicago or in a village in Syria or the Central African Republic during the “unrest” will have some “unusual” behavioral characteristics. That gets the therapist into “divorce court” scenario of He/she said vs. he/she said but with automatic weapons.

    A therapist probably has to be aware of lthe potential contribution of both the genetic and environmental factors without being too infatuated by the details or the current social ideology. It isn’t always “sex”. The patient/client isn’t always a “victim”. Some clear “victims” are quite functional and “well adjusted”. I think it is notable that there are media reports of individuals diagnosed with PTSD who have never been in a combat environment. Apparently, the highly regimented but open ended (What’s next?) military environment is highly stressful for some individuals (genetics?).

    I can’t speak to the estimate that 80% of schizophrenia is genetic, but even so, I agree that the therapist is more important than the theory. We are very adaptable critters.

  49. clipmaker says:

    If anyone cares there is a hacker news thread about this book review:

    https://news.ycombinator.com/item?id=21522600

    That’s how I found my way here, should have mentioned earlier.

  50. newsroot says:

    The story about troubled youths performing Shakespeare is almost exactly the plot of HBO’s Barry, where a Iraq war vet / hit man (Bill Hader) with PTSD like issues joins a local acting class. It’s actually a great show and that description doesn’t do it justice – it’s funny and has some great twists. Recommend.

  51. FlorianDietz says:

    I am not a psychologist, but I research AI and I can see some similarities here. For those with more knowledge about psychology, how good does this description of PTSD sound?

    Trauma sets a new reference level for the type of experiences you should expect. PTSD is when the brain overreacts while doing this.

    Most of the treatment options listed in this article help with resetting the reference level: They force repeated exposure to more normal stimuli levels, while also keeping the patient in a mental state where they are receptive to adapting their reference level.

    A way to test this hypothesis: Check if PTSD happens more often to people who otherwise lived sheltered lives than to people who are exposed to varying levels of horror throughout their lives up to the time of the trauma. This hypothesis would predict this to be true. It would also predict that fixing childhood trauma is both different and harder than adult trauma, because the child had fewer non-traumatic experiences against which the traumatic experiences stand in contrast.

    • clipmaker says:

      Rather than a new reference level it’s more like a closed loop of subconscious processing that stays with the person for potentially decades because it stays out of contact with the outside world. There’s a description in a Yeats poem about a cycle repeating over and over that in retrospect describes that.

      Here is a very powerful illustrated depiction:

      http://nautil.us/issue/23/dominoes/ptsd-the-wound-that-never-heals

    • cuke says:

      I believe the research we have shows that for soldiers in any case that childhood trauma/adversity makes them more likely to develop PTSD from combat trauma. So prior traumatic exposure is a risk factor for developing PTSD from later trauma.

      Later trauma is very commonly layered on top of earlier trauma so in that sense it’s harder to “fix” childhood trauma in an adult because usually more bad stuff has happened to them since, while it’s usually easier to “fix” childhood trauma in childhood, though it doesn’t happen nearly enough.

  52. blumenko says:

    Re: APA categorizations by symptoms rather than cause
    I don’t think this is true. For example part of the ADHD diagnostic criteria under DSM 5
    ” Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal). ”
    What the APA does is have a bunch of idiopathic syndromes, like depression, schizophrenia etc. Whenever any case can be explained by factors that can’t be the cause of the majority of cases of the syndrome, then it is immediately excluded. So if trauma is not the cause of the majority of e.g. ADHD, but say 30%, by the APA philosophy trauma caused ADHD should be excluded from being called ADHD and should be grouped under trauma.

    • cuke says:

      This is called differential diagnosis and isn’t really speaking to causes; it’s more just a way of distinguishing between diagnoses that have overlapping symptoms.

  53. Timewinders says:

    I once read a book about the Argentinian Dirty War and some of the accounts of torture victims really stuck with me and IMO explain why dissociation occurs and its role as a very beneficial defense mechanism. Many of the victims’ accounts described how they experienced extreme pain during torture, but it was much worse during the first few sessions. Over time they managed to adapt to an extent, because by feeling disconnected from their bodies the torture was a little bit more tolerable. For many of them it helped them survive to the end of the war, though of course it made it difficult for them to reintegrate into society.

  54. AL says:

    Has anyone looked for PTSD in today’s limited-contact primitive tribes? Scott’s observation that PTSD-inducing events appear to have been ubiquitous in our evolutionary environment, yet we don’t seem to have an adapted response to it, is thought-provoking.

    Maybe there’s a qualitative difference in how people in, say hunter-gatherer tribes experienced those events, and how people experience traumatic events today?

    This is kind of a sloppy and crude observation, but our ancestors had no access to bach, literature, history, or really any of the networked culture/knowledge that define who we are today. Maybe back then being eaten by a lion (or watching someone get eaten) was just an assault against your body, whereas today such a trauma is also an assault against Civilization. ?

    • mtl1882 says:

      There are a few theories discussed in this thread, but one idea is that it may well *be* the adapted response to certain types of trauma, allowing the person to navigate the new dangerous reality he or she must live in, such as constant warfare, enslavement, or risk of sexual assault. This is where hyper-vigilance and emotional numbing would be helpful. The person is ill-adapted for a life where everything is going well, and the issue today is that there is often the potential to leave the traumatic situation and return to a very safe life. Additionally, there is the idea that it is a failure mode for a normally helpful adaptation, when someone is stuck in the traumatic situation and unable to react normally to defend themselves. Back then, things tended to be over pretty quickly–you got away from the predator, or you didn’t. Our very organized civilization makes it very easy for people to be trapped in situations in which they can’t effectively fight back and in which the right reaction is not clear. I think being so networked definitely has an effect–the trauma is infused with a lot of meaning is probably something talked about when it happens to other people. And our society sort of operates on the idea you should be trusting, emotionally forthcoming, and feel generally safe, which would be a lot less tenable in previous times, even if they had very trusting bonds within their communities. A certain amount of vigilance and uncertainty was just part of daily life.

      • AL says:

        I’m not questioning the trapped-reality theory (you’re in a long-term bad situation you can’t escape, make the best of it); rather, I’m curious about the experiential difference, post-attack, between two hypothetical lion victims, our primitive survivalist living in the ancestral Savanah, and say a mall-shopper in present-day Scottsdale, AZ, both of whom survive a lion encounter.

        Both attacks are over quickly enough so that neither victim ends up in a TR scenario.  
        After the news interviews, I imagine our mall survivor in bed, in her room (assuming she’s not in the hospital), with the curtains drawn, maybe looking at texts from friends and family, or maybe just ruminating about the attack and *what it means*. 

        Meanwhile PS in contrast is back in motion, maybe digging up grubs or climbing a tree to get at some half-ripe fruit or heck maybe back on the run because there’s another lion out there.

        I don’t know how to conceptualize PS’s thought stream (does she even think in “thoughts”?) but I bet it doesn’t involve a monologue about being betrayed by people, institutions, or Reality.  Did PS ever think she was safe in the first place?  She can’t even count on eating tomorrow!

        PS’s response to the attack is going to be inherently kinesthetic whereas MS’s is inherently cerebral.  MS feels disembodied in a way, perhaps, that PS never can.

        These ideas are interesting to me.  Thanks for the response!

        • mtl1882 says:

          The ideas are definitely interesting, and I agree with your assessment of the thought process–I think it is easier for us to feel “disembodied” for a lot of reasons, and that this has more effects that we would acknowledge.

  55. thetitaniumdragon says:

    Intrusive thoughts are part of the diagnostic criteria for PTSD, but it’s not the only disorder with them. I’ve read that there’s a relatively high incidence of co-morbidity between OCD and PTSD, which is interesting, but also might imply that maybe some of these things are different symptoms of some of the same underlying frailties, for lack of a better term, manifesting in different ways – someone with OCD is going to feel like their hands are dirty and they need to wash them, while someone with PTSD might freak out and feel like they’re in a combat zone again and start acting like that.

    It makes me wonder sometimes if perhaps PTSD is really just triggering pre-existing psychological issues and making them far worse, rather than actually being a thing that is generated unto itself, so you either will develop issues or you won’t, based on preexisting factors. This could explain why we see weird patterns in people suffering from it – if you screen against these things heavily in people who are most directly exposed to trying situations, you could well see your badass commandos who drop in behind enemy lines and slit people’s throats in their sleep have a lower rate of PTSD than the guys who sit in base camp all day listening to guns go off in the distance, because the former group selects against people who are psychologically frail (or, alternatively, the training is sufficiently traumatic that most people who would develop psychological disorders, do so before they’re actually deployed).

    For instance, Navy SEALS seem to stand up a lot better to stress than “normal” troops do, which is the source of some study. People are hoping this can be learned, but I suspect it is actually a result of screening out people who have potential underlying issues.

  56. The original Mr. X says:

    Here’s an interesting video: “Battle fatigue — did it affect soldiers in the ancient world?” The speaker basically endorses the theory that ancient warfare was less intense than modern warfare, and so cases of PTSD were less common (although not entirely unknown).

  57. CallumGow says:

    I read this book and didn’t like it at all, it was very long and hard to read.

  58. thales00 says:

    Does van der Kolk provide a citation for “standard textbook of psychiatry at the time” with the shocking quotes about the alleged benefits of incest? If not, does anyone know which textbook this was? Some quick searching on my part was not turning up anything besides TBKtS for the quoted material (“such incestuous activity diminishes the subject’s chance of psychosis, and allows for a better adjustment to the external world.”) . . .