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> First, I think van der Kolk downplays the importance of the APA’s philosophical commitment to categorizing by symptoms rather than cause. Consider four patien

by imgabe 7y ago

> 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.

barry-cotter 7y ago
> This seems like a problem with the APA. Why would they categorize around symptoms? Because the APA is well aware that for many if not most psychiatric illnesses they are at the “fever” level of specificity in diagnosis, not “malaria” or “influenza”. But they have treatments that work for fever and very limited insight into the etiology of the diseases they work with. > The same symptoms can have different root causes and would then require different treatments. So doesn't it make sense to categorize around root causes? If they could they would. I’m sure there are examples of where a single psychiatric illnesses’ etiology has been uncovered and then they’ve broken it out into its own thing, and recommended the specific treatment for it that reliably works.
nabnob 7y ago
I thought all medicine used differential diagnosis, where you start with symptoms and gradually eliminate potential causes, until you're left with the most likely cause.
heisenbit 7y ago
The first step to good treatment is acurate diagnosis. It stands to reason to group by symptoms could support diagnosis as a roadmap. It narrows down what needs to be considered and it ensures relevant possibilities are not overlooked. If ones interest is in research and understanding underlying causes some of the symptomatic categories are not helpful. People pushing the boundaries of knowledge have to structure these domains and will come up with new terminology. This terminology will not easily map to the symptomatic view. The rest of medicine may look like being interested in root causes. And where there is easy and accurate tests available that is true. There are areas in medicine where knowledge is limited and treatment is symptom focused. AMA's approach is middle age - but our knowledge is on middle age level compared to what we know e.g. how muscles work. In psychiatry there is a huge gap and misdiagnosis is very common and does real damage. To compound the issue diagnosis is linked to insurance payments which considering the fuzziness of knowledge frankly scary. I don't think much progress comes from restructuring or optimizing existing categories and labels. What will have an impact if we got a sufficiently large set of more narrow conditions with reliable tests. Then the old system will be swept away. Until then it will be hit and miss and the best one can hope for is an educated counterpart who is keeping an open mind and is able to observe well.
nostrademons 7y ago
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 7y ago
  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.

by imgabe 7y ago

barry-cotter 7y ago

> This seems like a problem with the APA. Why would they categorize around symptoms? Because the APA is well aware that for many if not most psychiatric illnesses they are at the “fever” level of specificity in diagnosis, not “malaria” or “influenza”. But they have treatments that work for fever and very limited insight into the etiology of the diseases they work with. > The same symptoms can have different root causes and would then require different treatments. So doesn't it make sense to categorize around root causes? If they could they would. I’m sure there are examples of where a single psychiatric illnesses’ etiology has been uncovered and then they’ve broken it out into its own thing, and recommended the specific treatment for it that reliably works.

nabnob 7y ago

I thought all medicine used differential diagnosis, where you start with symptoms and gradually eliminate potential causes, until you're left with the most likely cause.

heisenbit 7y ago

The first step to good treatment is acurate diagnosis. It stands to reason to group by symptoms could support diagnosis as a roadmap. It narrows down what needs to be considered and it ensures relevant possibilities are not overlooked. If ones interest is in research and understanding underlying causes some of the symptomatic categories are not helpful. People pushing the boundaries of knowledge have to structure these domains and will come up with new terminology. This terminology will not easily map to the symptomatic view. The rest of medicine may look like being interested in root causes. And where there is easy and accurate tests available that is true. There are areas in medicine where knowledge is limited and treatment is symptom focused. AMA's approach is middle age - but our knowledge is on middle age level compared to what we know e.g. how muscles work. In psychiatry there is a huge gap and misdiagnosis is very common and does real damage. To compound the issue diagnosis is linked to insurance payments which considering the fuzziness of knowledge frankly scary. I don't think much progress comes from restructuring or optimizing existing categories and labels. What will have an impact if we got a sufficiently large set of more narrow conditions with reliable tests. Then the old system will be swept away. Until then it will be hit and miss and the best one can hope for is an educated counterpart who is keeping an open mind and is able to observe well.

nostrademons 7y ago

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 7y ago
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.