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.