
Book Review: The Body Keeps the Score - rayalez
https://slatestarcodex.com/2019/11/12/book-review-the-body-keeps-the-score/
======
imgabe
> First, I think van der Kolk downplays the importance of the APA’s
> philosophical commitment to categorizing by symptoms rather than cause.
> Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor
> concentration caused by child abuse. Bob has poor concentration caused by
> bad genes. Carol throws tantrums because child abuse. Dan throws tantrums
> because bad genes. The current DSM would categorize Alice and Bob as ADHD,
> and Carol and Dan as intermittent explosive disorder. Van der Kolk would
> like to classify Alice and Carol as having Developmental Trauma Disorder,
> and Bob and Dan as…I don’t know. Bad Gene Disorder? Seems sketchy. When the
> APA decides not to do that, they’re not necessarily rejecting the
> seriousness of child abuse, only saying it’s not the kind of thing they
> build their categories around.

This seems like a problem with the APA. Why would they categorize around
symptoms? The same symptoms can have different root causes and would then
require different treatments. So doesn't it make sense to categorize around
root causes?

The rest of medicine seems to be more concerned with causes. A sore throat
might be a cold, or it might be cancer. Obviously they require different
treatments, so they don't lump them all into "sore throat" and do the same
thing every time there's a sore throat.

Likewise if someone exhibits the symptom of ADHD and the cause is "Bad Genes"
but you're trying to treat them for non-existent trauma, it doesn't seem like
it's going to be effective.

~~~
nostrademons
A lot of diseases are treated symptomatically. Every time the doctor
prescribes aspirin/Tylenol/ibuprofen, rest & fluids, cough suppressants, or
anti-emetics, you're treating the symptoms. Rest, isolation, and IV fluids for
Ebola is treating the symptoms, and does it very effectively, to the extent
that the death rate from Ebola is 10% in developed countries but 80% in the
DRC. Psychodynamics, CBT, DBT, and most other types of talk therapy treats
symptoms, though I think what we're finding out about the mind is that there's
a bit of a causal loop and if you treat the symptoms long enough that _is_ the
root cause. To the extend that medication treats root causes of psychiatric
illnesses it does so in a very blunt way; wasn't there just a HN comment to
the effect of 'People like to say things like "seratonin is the drug that
makes you happy," or "oxytocin is the drug that makes you feel love," or
"dopamine is the brain's reward mechanism," but those statements are
simplified to the point of being wrong.' [1]. Our regular treatments for
injuries like burns, acute organ failure like pancreatitis, or physical trauma
like car accidents is to treat the symptoms until the body has time to heal
itself.

Oftentimes the root cause in medicine is something we can't fix, and sometimes
something we can't even identify. Biology's the domain of complex causes,
where few things have a single cause and a lot of things are interlocking
systems governed by homeostasis.

[1]
[https://news.ycombinator.com/item?id=21519901](https://news.ycombinator.com/item?id=21519901)

~~~
raducu
Amen to treating symptoms!

I feel like I've wasted years and a lot of money with psychotherapists who
insist on bullshit root causes.

Treating symptoms allows you to break the problem into smaller issues, monitor
progress, change course and so on.

There is no treating "root cause" \-- the root cause happened dacades ago; it
allows lousy psychotherapists to continue to be lousy psychotherapists.

There is no way to objectively quantify the root cause and to train
psychotherapists to "treat the root cause".

The "treat the root cause" psychoterapies, starting with psychoanalisis are
just bullshit psychotherapies, no better than the "detoxifying" and "holistic"
diets.

------
jacek
Another summary of the book that was discussed on HN three weeks ago:
[https://praxis.fortelabs.co/the-body-keeps-the-score-
summary...](https://praxis.fortelabs.co/the-body-keeps-the-score-summary/)

Discussion:
[https://news.ycombinator.com/item?id=21340636](https://news.ycombinator.com/item?id=21340636)

------
keeptrying
This might be one of the only books that I would classify as a “must read”.

The perspective of being able to debug your own brain is invaluable and
understanding other methods to do the same are worth the price of the book.

Buy an electronic and paperback. Great book.

~~~
azeirah
I do agree. I stand with SSC's criticisms about the details, but I do believe
that despite its flaws, it does communicate a very important message
effectively.

Namely, that your mental health is part of your body, not part of your mind.

It really changed my perspective, where before I had contempt about my body,
saw it as a nuisance, I now understand I -am- my body. It's as much a part of
me as my mind.

It helped me look into the right direction for treatment and additional
resources.

~~~
jimmux
The other side of the coin that this book helped me to see is that I am not my
symptoms.

There were parts of my behaviour that held me back, but I thought were crucial
to my identity so I was reluctant to let them go. After I realised that they
were symptomatic of psychological injury and not part of my fundamental
identity, I allowed the change to happen.

It felt more like going through a process of healing in the same way that I
might treat a muscle strain, and not spend the rest of my life limping because
of a bad fall.

I realise that sounds a bit contradictory - I guess the idea is that my mind
is part of body and can be treated as such, which makes it necessary to
liberate the ego from the rest of the mind. It made the concept of mindfulness
finally click for me.

------
michael_j_ward
Interesting bit burried in section IV that I'm posting here in the likely
event that most people don't read that far.

TL/DR- he's mostly critical of the book, but provides this update:

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

~~~
alex504
Yes I found this very amusing. For several reasons:

\- Within a week he seems to have found that the content of the book was more
effective than years of his treatment of atleast one patient

\- He buries this as deeply within the article as possible

\- This experience casts light on the crux of my issue with the article, which
is that it is very much a "prereplication" book review.

The reality is that neither the author of the book or the review have solid
empirical evidence one way or the other, in terms of modern style studies. The
book review seems to be drawing an overly negative conclusion about the
research because of this fact. To me this is a demonstration of an
overreliance on empiricism that seems to dog alot of western medicine
practitioners in general.

I found this line very revealing:

>later studies – done in an atmosphere of boredom, by large multi-center
consortia – are almost always disappointing.

I'm not sure what the phrase "atmosphere of boredom" signifies but it doesn't
sound like a faithful attempt to get something to work. If you are doing any
of these treatments in an atmosphere of boredom will it actually be effective?
Is doing it in an atmosphere of boredom really a valid way of testing it?

I haven't read the book but will read it. It does seem to me that the thesis
of the book, that trauma causes the mind to disconnect from the body and
shapes the body, is something that Chinese medicine / Qi Gong practitioners
have known about for thousands of years. I don't have any empirical evidence
to back these specific practices but I have mountains of anecdotal evidence
that would seemingly be rejected by the author of the review.

~~~
GuiA
_> I'm not sure what the phrase "atmosphere of boredom" signifies but it
doesn't sound like a faithful attempt to get something to work. If you are
doing any of these treatments in an atmosphere of boredom will it actually be
effective?_

If you have a broken bone, it doesn’t matter how bored the nurse who sets your
cast is - as long as they follow established procedure, you have an extremely
high chance to make a good recovery.

The issue with psychiatry is that it doesn’t really follow that model for many
(most?) “conditions”. As the author points out, wild new approaches seem to
work when everyone is excited about them, and then fail to do much better than
a placebo when scaled out.

~~~
alex504
Clearly a big part of these approaches is the affect of placebo. Placebo is
also a big part of the impact of many parts of western medicine. In clinical
trials antidepressants barely outperform placebos for instance.

You've raised a good point that this makes it even harder to determine how
well something is working. Was it 100 percent placebo or did change take place
outside of the effect of the placebo?

However just because the placebo effect is present doesn't mean we should
dismiss it out of hand.

The term "scaling out" and a "boring environment" to me requires a treatment
as simple as for instance setting a broken bone. A procedure like this is very
easy to train someone to perform and there is relatively little in the way of
differentiation between patients. An arm is an arm, it's very easy to see the
problem as well as to see how a treatment is working.

But for instance in the case of acupuncture or qi gong or yoga, it would be
very hard to replicate on a large scale. The practitioner matters a huge
amount, as does the exact condition of the patient. Is the patient actually
trying ot do the yoga? Is the acupuncturist good (most aren't). What kind of
yoga is the person doing? Is the yoga or qi gong teacher leading them in the
right direction for their particular issue? It isn't nearly as simple as a
routine medical procedure.

I'm not saying that all of these treatments necessarily are effective. The
issue I have is how quickly some are to dismiss treatments as not being backed
up by evidence when the evidence will be very hard to come by, and ignoring
the nuance involved. Personally my experience has led me to believe that
acupuncture done by someone that knows what they are doing will work more than
a placebo. The same certainly goes for qi gong in my personal experience.

------
foobar_
On a minor pedantic note, its more like the amygdala keeps the score. There is
no difference between physical abuse and emotional abuse when it comes to the
final end result on the brain.

~~~
pjc50
That's .. the unsolved research question under discussion? As to whether there
is a score at all, where it is kept, and how it might be affected? And while
is seems there is some evidence, we're still in the middle of the replication
crisis?

~~~
Mahn
According to Dr. Sapolsky (Why Zebras Don't Get Ulcers, Behave), there's ample
evidence of enlarged, hyperactive amygdalas in chronically stressed
individuals, both on artificially stressed lab rats and when looking at
differences in individual human beings.

------
docdeek
>> The standard textbook of psychiatry at the time stated that incest was
extremely rare in the United States, cocurring about once in every million
women.

This would seem incredibly low, even for a non-expert. At the time, as the
article notes, there were 100 million women in the US - for incest to only
impact 100 women in the country and yet be something that there is a word
(noun) for, laws against, and historical records of stretching back millenia
stretches credibility, surely.

~~~
pjc50
This sounds like more confirmation that the old standard textbooks about
psychiatry contained far more traditional belief and sexual pseudoscience than
the profession was willing to admit. Remember how long it took to get
homosexuality removed from the DSM?

It's a bit like global warming denialism. Admitting that child abuse within
families is not extremely rare has absolutely horrifying implications for
people's moral universes. Much easier to deny it happens.

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

"We have some treatments; they seem to work sometimes, although we don't
really understand why and they're not entirely reliable" is still a far better
place than "we have no treatments", which in turn is far better than "your
condition does not exist and you are lying". I feel slightly better about SSC
for admitting this and being willing to carry on working in an uncertain
environment.

~~~
slfnflctd
The practice of psychiatry is filled with disasters, and has been more of a
reflection of our culture than a science for much of its history. It is good
of you to point out how there's been steady improvement-- we should remember
that the field's utility can be improved.

I still would hesitate to recommend a psychiatrist's services to anyone
without an extensive disclaimer, though. [In a way that I wouldn't with a
general practitioner, or even a talk therapist.] It would be great if that
changed one day.

~~~
fellow_human
Wondering what the disclaimer would be? And why wouldn't it apply to a talk
therapist?

~~~
slfnflctd
The key distinction is that a talk therapist doesn't prescribe drugs. These
drugs are poorly understood, as are the conditions they ostensibly help treat,
and there are a great many concerns about the validity of much of the research
that went into justifying their use. There are also large numbers of people
reporting long term side effects from said drugs which arguably made the
patient worse off. I would caution everyone to avoid them in all but the most
clear cut, 'textbook' cases.

I've also noticed - both personally and from talking with others - that a
disturbing number of practitioners in this field seem to lack empathy and/or
professionalism, which in my view are absolutely critical when dealing with
mental health issues.

------
fellow_human
> 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 not sure of the author is purposefully ignorant about this, but the
original ACE study was done on middle class households, 75% white.
[https://www.npr.org/sections/health-
shots/2018/09/17/6487108...](https://www.npr.org/sections/health-
shots/2018/09/17/648710859/childhood-trauma-and-its-lifelong-health-effects-
more-prevalent-among-minorities)

~~~
SpicyLemonZest
I'm not sure I follow. The US is 75% white, and by many definitions (I can't
tell from this article how they defined it) is mostly middle class.

~~~
fellow_human
Perhaps whiteness is irrelevant, perhaps not. Socioeconomic background was
controlled for the fact that the participants were from the middle class.
Whether that's inherent to the US population due to the fact that it's a big
part of it, or not is irrelevant. Unless I've missed your point?

------
patrec
> Like so many things, PTSD feels self-evident once you know about it.

Only from the myopic perspective of people only used to a life of luxury and
ease.

Throughout most of history several of the people most close to you would have
made an early and often quite unpleasant exit before you reached adulthood --
most of your siblings and children would probably not make it into adulthood
and women had a double digit chance of dying from child birth[1]. And that
held true even if you were an affluent member of a relatively stable and
successful society.

[1]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1139114/pdf/med...](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1139114/pdf/medhist00088-0087.pdf)

So a priori it seems extremely unlikely to me that severely unpleasant
experiences have psychologically crippling effects on a majority of people.
Because that would seem to be extremely maladaptive for almost all of the last
few millenia.

~~~
vector_spaces
A common misperception about ptsd is that it results from discrete traumatic
events or episodes. It doesn't in general. More often it results from discrete
or continuous traumatic events or episodes _together with_ one or more of
alienation, lack of social support, or ostracization. That is one reason why
not everyone who experiences a shared traumatic event will develop PTSD.

So what is maladaptive are there breakdown in social ties and cultural/social
infrastructure and process for supporting humans going though hell, not, in
fact, my PTSD, thanks

~~~
zsz
1\. PTSD is in actuality frequently triggered by a single, discrete, traumatic
event. 2\. The feelings of ostracization/alienation and general disengagement
from social discourse are indeed well known markers -- except, they follow,
rather than lead the onset of PTSD. In other words, they manifest as a result
of PTSD -- not the other way around.

Source: [https://www.psychiatry.org/patients-families/ptsd/what-is-
pt...](https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd)

------
afpx
The reviewer shows lack of critical thinking and lack of understanding of how
genes work when he goes on a political rant at the end of the first section.
Armchair scientists have got to go.

~~~
skybrian
It seemed reasonable to me, but I'm no expert. What do you think he got wrong
and do you have any recommendations for further reading?

~~~
afpx
My issue is that he implies that there’s something nefarious going on because
of a lack of discussion of genes. I claim he lacks critical thinking because
he ignores that the book’s primary audience is a person with past trauma, not
someone with sufficient biological understanding to get the nuances of
“genes”. So, instead of implying some political agenda, it’s safer to infer
that the author left out the discussions to prevent an overly-generalized
explanation that may cause more harm. For example, see what happened with
BRCA. Look also what happened with “The Bell Curve”. It’s easy for a lay
reader to view genetics as _the_ cause rather than one (extremely nuanced)
factor of many. And, when we see that many victims of trauma are, by
circumstance, at the lower end of the social class spectrum, this leads down a
slippery slope.

Second, medical doctors aren’t usually also research scientists. They’re
specialists in clinical treatment of physiology. He’s probably smart and well
educated. But, not a scientist. As an analogy, it’s similar to when I cringe
when I see a programmer try to write a new cryptography protocol or algorithm.
Some things are complex and risky enough to leave to the experts.

~~~
skybrian
I haven't read the book so I don't know who's right. But this sounds a little
too much like "how dare he question authority?"

The reviewer is a doctor and doctors are supposed to be able to understand
genetics and read the scientific literature. Maybe not at the same level as a
specialist, being able to follow along and tell good science from bad is
useful.

As a programmer, I wouldn't be so foolish as to write my own cryptography
code, but I understand the basic principles, I do try to keep up, and I expect
a researcher writing a book to discuss security issues without dumbing it down
too much. If I were reviewing a book saying something about cryptography that
seems wrong I would definitely point it out. (Though, not being an expert, it
might be in the form of asking questions.)

We can't get anywhere without trusting experts, but that doesn't mean we can't
read critically.

