A couple comments on PTSD:

(1) I've read that some believe that combat PTSD actually could have been due to, for some people, actual lesions in the brain due to being regularly exposed explosions. I don't know if that's true, but it would explain the lack of PTSD in the past.

(2) Also, a disproportionately large number of people with PTSD have sleep apnea, which is a disease of modernity (jaw sizes have shrunk and tongue sizes have grown). Some people theorize a connection between sleep disorders and an inability to overcome past trauma.

A similar thought on ADHD:

(1) Several studies have found a large number of children with ADHD have sleep disorders. Several find that a slight majority have sleep apnea. Also, note that sleep apnea, being connected to facial structure, is very genetic. If there are cultures that don't recognize ADHD or something very much like it, I would think it is because they don't have much it, which may make sense if it is, at least partially, caused by modern sleep disorders.

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One thought on the PTSD subject -- is this fully explained by "Blast induced trauma" (AKA shell shock) as the source of PTSD in soldiers? I'm not sure how many blasts soldiers in the 19th century were subjected to, but I'd guess it's much less than in modern warfare with high explosives, and it's possible it could be effectively zero exposure if cannonballs don't cause this kind of concussion on impact. Certainly if you go back before gunpowder there was no blasts.

It seems there's some research backing up this link, e.g. https://pubmed.ncbi.nlm.nih.gov/18234750/.

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Re ADHD vs anorexia - wait, you think being bad at concentrating/executive function/prefrontal cortex type stuff feels closer to the hardware level than being bad at the desire/urge/motivation to eat, which is a very primal thing that exists in some of the simplest brains?

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Others in the comments are asking whether it's a physical consequence of blasts or explosions. My question is whether it isn't simply the psychological effect of that: in modern warfare there are constant blasts, artillery, explosions, grenades, and the possibility of instant death at any time. This also puts you in the peak state of stress much longer. You're at the mercy of sudden incidents that you can't control or see coming.

I sifted through the comments on the blog post, and found at least one other person speculating about the same.

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Somehow I missed the original thread of this which is too bad. Peter Levine’s somatic experiencing has a lot to say about this. So does Charles Hoge (military psychiatrist who has also deployed), who has published a variety of research as well as “Once a warrior, always a warrior.” So does Resmaa Menakem.

The US culture-at-large is not known for grieving well, releasing emotion, and with very few somatic grief skills, people are walking into dangerous situations with their energy already stuck. Wailing, drumming, singing, staying awake for days at a time, gathering in large groups to celebrate loudly regardless of how “bad” things are, behaviors like this train the spirit to remain present, release stress and intentionally enact feelings. So people have more skills for rebalancing when challenging things happen and they can nip Ptsd in the bud more often.

Much of modern employment is very brain - centric, so memory and thought issues become evident which were less clear when throwing hay bales was the main activity for many a veteran. Also, people now survive experiences that killed prior generations if military, due to medical and transportation advances. So survivors may have more long term health issues now because they are surviving things which no one used to survive.

See also moral injury. There is a lot more to say but I’ll stop here.

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"I am sympathetic to this based on an experience I had, where I was pretty bad at tolerating noise, but kind of within the normal human spectrum and never thought much of it, and then I lived with a noisy roommate who characterized my distaste for noise as freakish and psychiatric-level, and after that, every time I heard a noise I started panicking and questioning whether I was going to have some sort of freakish and psychiatric-level reaction to it, and this became so unpleasant that now I do have a freakish and psychiatric-level noise intolerance - or at least this is how I remember it."

Does this mean the piece about Nodrumia was influenced by personal experience? Sounds very much like it!

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"Crimkadid is also responsible for this long twitter thread on variance in schizophrenia, which is poorly-supported, bizarre, and racist, but otherwise excellent"

What an absurdly nuanced way to describe something.

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I also wonder about the role of medicine in increasing the prevalence of PTSD. I recently listened to an excellent Rough Translation podcast series about a solider with PTSD from having lost three limbs in Afghanistan. A century ago he would not have had PTSD; he would have died. (I see the Globe article makes this point as well.)

The Globe article about 45% of veterans receiving benefits reminds me of the This American Life episode Trends with Benefits, which explored how disability rates are rising overall as disability is one of very few viable welfare programs accessible to many struggling Americans: https://www.thisamericanlife.org/490/trends-with-benefits

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>One theme running through this book review (that is particularly visible in the discussion of PTSD) is the Western trend to diagnose more and more things as psychiatric illnesses.

I think this has a lot to do with us living in a capitalist/authority-based/scientismist society where if you have any problem of any kind, you are expected to pay a professional to deal with it rather than seeking any otehr type of solution, and for many problems you cannot possibly afford treatment unless your health insurance will cover it, and your health insurance will not cover it unless you have a formal diagnosis relating to it.

I strongly suspect that if medical and psychological care were freely available for anyone who wanted help with something even if they had no diagnosis, and meds could be prescribed without a formal diagnosis, the overall rates of diagnosis would go down like 80%.

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The TED talk https://www.ted.com/talks/sebastian_junger_our_lonely_society_makes_it_hard_to_come_home_from_war/transcript?language=en gives more evidence that PTSD is very much rooted in social stories and reactions, and posits that a significant part of PTSD is alienation. An interesting statistic: 50% of US veterans file for PTSD compensation even though only about 10% of US veterans have seen combat. By contrast, the rate of PTSD in the Israeli army is 1% (the TED talk suggests that this is because, unlike in the US, everyone in Israel knows what it's like to be in the army because participation is mandatory).

It seems like PTSD might either be a result of not knowing how to integrate your experiences with the social role you're expected to play (or perhaps in particularly perverse cases, experiencing PTSD is part of the social role you're expected to play)?

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I can't figure out what's supposed to be excellent about that Crimkadid twitter thread. It looks like a pile of just-so stories with a light sprinkling of science, designed to justify irrational prejudices.

...this isn't the first time I've had this reaction to something you've posted. Not even the first time I've had it to something you've linked from a reactionary. With all due respect, I think you're much too tolerant of people making up plausible-sounding semi-scientific explanations for already-known facts. Reality offers endless degrees of freedom; it's always easy to come up with a story explaining how x y and z are all natural consequences of your pre-existing beliefs.

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I don't remember where I read this, but I remember a reading about a hypothesis that in the past there might have been fewer post-battle mental health issues because soldiers would need to walk back home, which might have taken weeks. In this time, they might have talked with eachother about the terrible things that happened, and integrated the experience somewhat.

In contrast, now they might be flown back and be home in days, ripped from the social group that understands their experience and thrown back into regular society.

This seems not unreasonable to me.

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Okay, I have opinions on PTSD both from a professional perspective, experiential practice, and an interest in warfare and combat.

I first came across this problem when at a ward round. My consultant asked the junior doctors a general question about PTSD. None of them answered. As the nurse present, being newly qualified and over excited at my first ever ward round ever I piped up and gave an answer, which impressed the consultant and probably embarrassed the junior doctors. My bad.

Anyway, to get to the point; the difference centers around the weight you give to the confounding variables: TBI from shock blasts, drug abuse (Vietnam veterans mediated their feelings with a wide range of drugs, plus the military issues amphetamines or equivalents too), and finally, the point I raised the training has changed.

Back in the good old days (insert date of choice) training was based around generic targets, and studies should that in combat men would choose to fire high, rather than shoot to kill another person. After WW2 Skinner was got involved with training to try and overcome this problem.

The results of this were first seen in the Korean War, and further improved by the time of the Vietnam war. Today a Western military will see approximately 98% of its soldiers shoot to kill compared to the WW2 rate of approximately 2%.

Okay, this doesn't account for for pre-industrial armies and antiquity, but one could make an argument that those suited to the task of killing were self chosen, being those men and women who would see fighting and killing as their calling. Arguable, but it is a theory that fits the evidence and provides a tool for understanding the problem.

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A counterpoint to the ACOUP post: Is today's PTSD the same phenomenon as "being haunted by ghosts" in the past?

> Cross-cultural psychologists have observed that, regardless of cultural background, people who suffer persistent emotional disturbances in the wake of a traumatic event exhibit intrusive memory symptoms in some form. Here in the US, these are closely related to what we commonly call "flashbacks." For the Romans, people experiencing intrusive memories were said to be haunted by ghosts. These individuals show up in historical, philosophical, and even medical texts. Josephus, who was an outsider to Roman culture, also describes this phenomenon in his history of The Great Revolt. Those haunted by ghosts are constantly depicted showing many symptoms which would be familiar to the modern PTSD sufferer. Insomnia, depression, mood swings, being easily startled, frequent eye movement, alertness all day and night, paranoia, avoidance of crowds, suicidal thoughts/attempts, loss of appetite, shaking/shivering, self-hatred, and impulsive violence have all turned up in association with these individuals. Since in almost every case the person experiencing these things had made himself an object of public shame, the "ghosts" in question often came in the form of those he had killed or wronged in the past. These would either appear spontaneously to the sufferer, or would come in the form of vivid, frightening nightmares. The key component to these experiences, as with modern cases of PTSD, was that the sufferer had no control over his own symptoms. Thoughts or vivid memories would occur unexpectedly and uncontrollably. It is easy to see why the Romans, who were religiously superstitious to begin with, would attribute such things to the foul play of malicious spirits.

Origin: https://www.reddit.com/r/AskHistorians/comments/1j6ssm/are_there_any_indications_of_combat_ptsd_in/cbbvfib/

(I'm posting this here, copy+pasting from a comment on ACOUP, which copied from a comment on Hacker News, which copied from the AskHistorians thread. Blog comments are like medieval letters.)

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"This is a great point and a great example."

Is it? I'm highly dubious of any claim that makes blanket statements about child sexual abuse, especially obviously ridiculous ones such as a claim that there was total denial of it occuring before the 1980s.

I'll also note that the current Western narrative on child sexual abuse seems incapable of understanding that people can genuinely hold beliefs that go against its narrative.

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"a lot of the educated opinion has switched over to crimkadid’s view (see eg McGrath 2008), which calls the uniformity hypothesis a “dogma”."

I'm interested in this, because Ireland allegedly has a high incidence of schizophrenia. Or allegedly had. Looking up online I can't access the full text of various studies but there does seem to be a ding-dong going on about this ("your study figures are crap" "come outside and say that to my face").



From the scraps I can glean, this seems to be due to:

(1) Irish emigrants turning up in America were hospitalised for schizophrenia at a high(?) rate

(2) Irish schizophrenia was seen to be a rural, rather than urbanised, illness (not surprising there) particularly elevated in the West of Ireland

(3) Revision on this later claims it was because patients first treated/hospitalised for it were using the medical services afterwards as a replacement social support scheme, so they were turning back up to be re-admitted to hospital (I'm torn on this one, as Irish hospitals are not a luxury experience but on the other hand if you're an Irish bachelor farmer in your 60s living up a mountain with nobody but the ghosts and the sheep for company, even an Irish hospital is better than that)


(4) Summation seems to be that Ireland does *not* have an unduly high rate but it's in line with other countries, which would seem to be on the side of uniformity rather than cultural difference?


Unless the "rural support system" hypothesis is true, and countries elsewhere also have people using the medical system as an ersatz community, so the actual incidence of schizophrenia is pretty much the same all over, but hospitalisation rates differ due to "the doctors said I needed aftercare so here I am, please admit me".

On the other hand, this report from 2019 tells a different story? Or at least, that hospitalisation figures remain high in Ireland:


"One-third of all in-patients on census night had a primary admissions diagnosis of schizophrenia, 16% had a diagnosis of depressive disorders, 10% had a diagnosis of organic mental disorders and almost 8% had a diagnosis of mania. Patients with a diagnosis of schizophrenia had the highest rate of hospitalisation, at 16.0 per 100,000, followed by depressive disorders, at 7.9, organic mental disorders, at 4.7 and mania, at 3.6.

Males had a higher rate of hospitalisation for schizophrenia than females, at 20.2 per 100,000 for males and 11.9 for females. Similarly, males had a higher rate of hospitalisation for organic mental disorders, at 5.6 compared with 3.9 for females. In contrast, females had a higher rate of hospitalisation for depressive disorders than males, with a rate of 9.2 for females and 6.6 for males.

Those with a diagnosis of schizophrenia had the highest rate of hospitalisation amongst all age groups in the 20–74 years age range, with rates ranging from 37.5 for the 65–74 years age group to 9.5 for the 20–24 years age group. Both schizophrenia and eating disorders had the highest rate of hospitalisation amongst the 18–19 years age group, at 5.9 each respectively. Organic mental disorders had the highest rate of hospitalisation amongst the 75 and over age group, at 52.6 per 100,000.

Schizophrenia also had the highest rate of hospitalisation in six of the ten socio-economic groups (farmers, agricultural workers, non-manual, manual skilled, semi-skilled and unskilled), while depressive disorders had the highest rate amongst higher professionals, lower professionals, employers and managers and own account workers.

...Schizophrenia continues to be the predominant diagnosis in adult units and hospitals, accounting for one-third of all patients resident, while depressive disorders was the predominant diagnosis amongst the under 18s, accounting for 37% of all under 18s. The proportion of in-patients with a primary diagnosis of schizophrenia remained at a similar level (34%) in 2010 compared to 33% in 2019 while the proportion of in-patients with intellectual disability declined from 6% in 2010 to 4% in 2019."

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>She felt a degree of bitterness toward her friends: almost as though they'd caused her to become a victim, not her attacker.

(warning: what follows is non-nuanced speculation about sexual abuse)

Given these arguments about guilt: https://www.lesswrong.com/posts/CZnBQtvDw33rmWpBD/guilt-another-gift-nobody-wants , I think this makes some sense.

If we assume that survivor's guilt is some kind of game-theoretic mechanism to prove your innocence, then we could expect that this only kicks in for very taboo things. If you did not know that what happened to you is taboo, then there is no need to prove your innocence with survivor's guilt (of course, getting survivor's guilt is not a *conscious* process, but I hope you get what I mean). But once you learn about how horrified everyone is of your experience, the survivor's guilt starts.

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> Other commenters bring up related arguments - doctors sometimes examine children’s genitals in ways that aren’t obviously different from what goes on in some child sex abuse cases; some tribes have rituals where adults do weird things to children’s genitals - in all these cases, because it’s socially accepted and people aren’t “supposed to” feel traumatized, they usually don’t.

I feel compelled to bring up a counter example. The first time I ever had sex, it was not consensual. I felt powerless and upset, but it was with my first boyfriend and it was not scary, and it didn't map to my expectation of what rape would be like, so I quietly accepted it and did my best to accept that my life now included this activity. I even came to kind of enjoy sex with him, sometimes.

I only went to a gyno much later, after we'd broken up for entirely unrelated reasons. And then, while they did the pap smear, I felt completely violated and vulnerable. The weight of every unwanted touch I'd ever had from my boyfriend seemed to come crashing down on me. It felt much more traumatizing than all of these previous experiences, even though the doctor was perfectly nice and as far as I can tell did everything right.

My reactions don't really make sense to me, but they don't really track with the view that going to the doctor is not traumatic either. I can easily be convinced that if I had no history of sexual assault, then the doctor visit would have gone way more smoothly, and I guess it was just a trigger and not its own trauma per se. But it feels like it was its own trauma anyway.

I haven't had sex since then, even though it's been years and I've had the opportunity several times. After realizing I actually had the choice to say no, it has always felt more compelling to exercise this choice, even though I am aware people seem to enjoy sex a lot and I might too if it was actually under my control.

And I haven't gone to the gyno again, even though I know I should, but it just feels unbearably scary.

All of that said, I don't think I have meaningful PTSD symptoms right now. Looking back, I do think I experienced them while I was dating that first boyfriend, but I attributed them to a previous sexual abuse experience that felt much more terrible and scary, even though it was not under the umbrella of what is normally called rape.

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On the second paragraph of the last entry: incentives create results. If there are (monetary) benefits of being sick, people will make themselves believe they are sick (psychologically or otherwise). Obviously this is not the case for everyone.

I am always amazed how many people in my country (the Netherlands) are on semi permanent sickleave so to speak: 817.000, 6.6 % of the working population. And this in a country with a very good, in practice free, healthcare system.

Other benefits are: getting attention and not having to take responsibility.

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> it’s strange that the PTSD symptoms associated with details of modern combat (ie a “soldier who doesn’t know when the next enemy might appear in a crowd of civilians”) so closely resemble the symptoms modern people get after natural disasters, sexual violence, etc.

A commonality I see with those three cases is a traumatizing event happening at an unpredictable moment in an environment you can't escape.

Your mind will work very hard to protect you from experiencing the enormous event again, so will pattern match even the tiniest details as possible warning signs. There is no such sign, but your mind will not take any chances, those rustling leaves might be a tiger after all.

But that clear lack of warning signs will also cause you to relive the event; the definitive signs haven't been found, so we must keep looking.

All the while you have a list of candidate signs, so every time one of those signs pop up: better safe than sorry, let's get that fight-or-flight going.

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Wouldn't it be fascinating to test which Western psychiatric interventions work cross-culturally, and which don't? Presumably medication would be better at it than psychotherapy, for instance? Then we will have data on which interventions are just our own witch-doctor treatments.

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Discussion of war previously as a positive good and the lack of connection to PTSD has me thinking about how it may influence groups ('cultures,' but not really) that have similar worldviews today, whether that be terrorist organizations, rebel groups, militias, etc. I'm sure research into PTSD and associated trauma rates in those populations is exceedingly difficult, but maybe there's something out there?

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Your explanation of child sex abuse sometimes not causing trauma definitely makes sense, but curious about an alternate theory... It does cause underlying trauma, but in ways that do not manifest directly in a person's life until it's directly discussed as taboo. In that case, couldn't it be seen as a positive that it's brought to the surface (making some kind of treatment possible) rather than unconsciously dealt with?

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Re: widespread pedophilia, I just read this article:

The German Experiment That Placed Foster Children with Pedophiles https://www.newyorker.com/magazine/2021/07/26/the-german-experiment-that-placed-foster-children-with-pedophiles

And the subsequent twitter thread that argues that pedophilia was popular among certain elites in the 70s https://twitter.com/razibkhan/status/1417548833593217042

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Growing up, I was taught that one of the important differences between Judaism and Christianity is that Judaism teaches that you should do right things and right thinking will follow, whereas Christianity teaches that you should believe right things and right actions will follow. And that this leads directly back to the central directives of each religion; “keep the mitzvot” and “believe in Jesus”, respectively.

Regardless of whether these ideas are prevalent in the West because of their respective religious teachings, it really feels to me like the field of psychology presupposes that right actions can only come from right thoughts. Perhaps they have to; it might be a very different field otherwise. I personally think they’re wrong and one of the themes I see in this Crazy Like Us discussion is pushing back and suggesting that in fact, contrary to what psychology teaches, right thoughts lead to right actions.

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Regarding creating trauma, one thing I *think* I've noticed by hanging out with some not-large-but-not-trivial number of Asian families is that how they handle bodyweight issues with kids seems better. If the kid is putting on weight, mom says "Hmm, you're getting a little fat so I made you a smaller plate". That's it. In contrast, American parents (or the stereotype of them at least) is to talk between themselves for a while to figure out how to approach the child gently about their weight, and when they finally do manage to say something, preface it as if they're preparing to tell them all the puppies in the world died, causing the kid to think their weight is a serious world issue and to subsequently experience anxiety about it.

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Glad to hear my comment was helpful!

Re: "I wouldn’t expect there to be enough people witnessing each other’s interactions with schizophrenic family members for this to spread across a culture. Maybe this is downstream of biological views of mental illness or something?"

I don't know, but best guess for the "Crazy Like Us" viewpoint is that a culture-bound "response to mental illness" role could spread through a society in a similar way to how a culture-bound "mentally ill" role spreads. So the depiction of John Nash in "A Beautiful Mind" influences how mental illness expresses as schizophrenia, just as the depiction of his wife Alicia influences how companionship expresses as a particular caretaker/illness-adjacent role within a family?

But, if you follow this idea, you would expect to see a change in this caretaker role accompany changes in the cultural expression of the illness, if the two are related. Maybe it would be easier to see for low-stakes common ailments like "how the rest of the family reacts to one of them getting a cold". Is there a lot of variation in this too, world-wide? And is that influenced by e.g. a character on an American TV show getting a cold, which is broadcast in Europe?

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About natural disasters and PTSD: I wonder if the abundance of information about natural disasters is contributing to duration and severity of anxiety etc people experience afterward.

I'm working off my own experience so I'll try to keep my example brief and dispassionate:

Talent/Phoenix, Oregon last September:

-We had no warning about the Almeda fire, the emergency alert system was not activated, and everyone evacuated at the last second. Three people were killed and 2500 structures burned.

-After the fire, everyone was distraught over the lack of information, so people turned to sharing their own information on Facebook: countless videos of burned neighborhoods, false reports of new fires, pictures of actual fires popping up all over the place.

-Residents also tuned into the police FB page, the fire department FB page, the police scanner, and ever-updating county evacuation maps.

-A major wildfire burned in the Rogue National Forest nearby, inundating the whole valley in thick smoke, and details of this fire were continuously posted/updated.

Given all this information, the residents of Talent and Phoenix lived with a sense of "nowhere is safe" for an extended period post-fire. Some people ended up with PTSD diagnoses, others didn't, and whether they lost a house didn't seem to matter. The people who I saw showing continuous signs of stress and anxiety happened to be those who continued to believe that nowhere is safe.

Of course, the *feeling* that nowhere is safe is a symptom of PTSD, and one that I've experienced. But as I notice my unsafe feelings abating with time/exposure/therapy, I'm seeing people who experienced far less trauma in the wake of the fire display more anxiety about fire season.

I wonder if the exposure to fire-related information is exacerbating their anxiety.

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I recommend A Collection of Unmitigated Pedantry in general.

Especially https://acoup.blog/category/collections/siege-of-gondor/ where I learned about some things that I missed despite repeated rereads - because I had no knowledge necessary to appreciate it.

Also, I learned a lot about real history from it.

Series about Sparta, about ancient farming, all of that is really interesting and I recommend it.

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My recent ADHD diagnosis has radically rocked my worldview even though it's been consistently suggested since I was in kindergarten to explain various issues. Some deeply un-rigorous thoughts:

1) I have really resented the outpouring of support and kindness from my "progressive" friends - the underlying sentiment appears to be that now I am no longer responsible for anything I do, and that attempts at self improvement or management (other than taking Adderall) are delusional in some way.

2) As Scott suggested, a mental disorder for which 5-10% of people meet the criteria is not a mental disorder. It's just "a way some people are." If we have built a society in which 5-10% of people need to be medicated in order to function, that strikes me as a dysfunctional society, not a society with a lot of dysfunctional people.

3) On the other hand, if Adderall is really as safe and effective as claimed I don't see any reason why 100% of people shouldn't be on it. :P

4) Scott also points out the obvious: a huge part of my struggle was navigating a career I'm bad at. Billing hours makes incentives run precisely backwards. Legal culture is obsessed with stereotypical "lawyerly image" over productivity.

There is limited room in the legal world for a person who is useless from 7-10AM every morning but can knock out an excellent brief at 10pm after a shower thought leads to a new idea for argument. That doesn't project a lawyerly "image" and costs the firm money - If most of your "work" gets done as a background process while you're faffing about, is that billable time?

tl;dr: "Being a bad lawyer" is not a mental disorder. Most people would make bad lawyers.

But more than that, my ADHD diagnosis is cultural in more ways than just "my society has more psychiatrists, and they need something to do." It's also a consequence of society being more global - I need to sell myself to strangers whose incentives include fast, System 1 judgments, and for whom taking a while to evaluate my unique strengths and weaknesses would be an unconscionable waste of time and energy. I am expected to have very set on-hours and off-hours and to conform to the appearance of productivity, even if that's not how my natural cycle works. My usefulness is measured in ways that fail to show me in a good light.

And, yes, perhaps most importantly, I expect to self-actualize as a lawyer/mathematician/rocket scientist/fitness guru/polymath instead of as a sustenance farmer who survives past 25 years old.

I'm inclined to treat all these things as negatives because they exclude me, even though most are decidedly not - set work hours are a win for most people. Performance metrics *should* overtake personal feelings that are often prone to bias. The availability of multiple life paths and resources to pursue them is a mostly unqualified good.

And yet these almost entirely positive things gave me ADHD :P.

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Perhaps the takeaway here is that, psychologically speaking, a lot more people are subject to the nocebo effect than we realized.

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I second the finding that PTSD was virtually unheard of in ancient soldiers. I also looked through the examples people usually cite, and they're thoroughly unconvincing. For example, one was that Roman slave sellers had to inform buyers if the slave had ever been attacked by a bear. The reasoning goes that if the buyer is worried about physical impairments from the attack, he can easily see them himself, so he must be worried about PTSD.

This is even more surprising because of how common war was for ancient people. In Rome, the gates of the Temple of Janus were open in wartime and closed in peacetime. The gates were open continuously from 225 BC to 29 BC. Also, it was standard for Rome to fight with two consular armies of two legions each, for a total of 20,000 men, half of which were Roman and the other half Italian allies. The population of Rome in c. 200 BC was maybe 500,000 people, so this was 4% of the male population under arms at any one time. Since there was no professional army and levies were conducted annually, the percentage of the male population with military experience is probably >15%. In comparison, modern USA has 0.8% of its male population under arms, and most of those have never been near an active combat zone.

Incidentally, I read a NYTimes article a while back that said drone pilots also get PTSD, even though they're completely safe. The article ascribes it to "moral injury". Not sure what to make of it: https://www.nytimes.com/2018/06/13/magazine/veterans-ptsd-drone-warrior-wounds.html

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Here's an experiment: Let's make up an entirely new form of mental illness with realistic sounding symptoms, and then try and spread awareness of it somewhere. If the ideas in "Crazy Like Us" are correct, maybe we'll see an epidemic of this new mental illness.

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re sexual abuse and cultural expectations: this reminds me of an anthropology paper about how people in different cultures experience rape differently because of their beliefs about its severity

From Christine Helliwell's "'It's Only a Penis': Rape, Feminism, and Difference" (CW is self-explanatory):

"In 1985 and 1986 I carried out anthropological fieldwork in the Dayak community of Gerai in Indonesian Borneo. One night in September 1985, a man of the village climbed through a window into the freestanding house where a widow lived with her elderly mother, younger (unmarried) sister, and young children. The widow awoke, in darkness, to feel the man inside her mosquito net, gripping her shoulder while he climbed under the blanket that covered her and her youngest child as they slept (her older children slept on mattresses nearby). He was whispering, "be quiet, be quiet!" She responded by sitting up in bed and pushing him violently, so that he stumbled backward, became entangled with her mosquito net, and then, finally free, moved across the floor toward the window. In the meantime, the woman climbed from her bed and pursued him, shouting his name several times as she did so. His hurried exit through the window, with his clothes now in considerable disarray, was accompanied by a stream of abuse from the woman and by excited interrogations from wakened neighbors in adjoining houses."

"I awoke the following morning to raucous laughter on the longhouse verandah outside my apartment where a group of elderly women gathered regularly to thresh, winnow, and pound rice. They were recounting this tale loudly, and with enormous enjoyment, to all in the immediate vicinity. As I came out of my door, one was engaged in mimicking the man climbing out the window, sarong falling down, genitals askew. Those others working or lounging near her on the verandah - both men and women - shrieked with laughter."

"When told the story, I was shocked and appalled. An unknown man had tried to climb into the bed of a woman in the dead, dark of night? I knew what this was called: attempted rape. The woman had seen the man and recognized him (so had others in the village, wakened by her shouting). I knew what he deserved: the full weight of the law. My own fear about being a single woman alone in a strange place, sleeping in a dwelling that could not be secured at night, bubbled to the surface. My feminist sentiments poured out. "How can you laugh?" I asked my women friends; "this is a very bad thing that he has tried to do." But my outrage simply served to fuel the hilarity. "No, not bad," said one of the old women (a particular friend of mine), "simply stupid.""

"I felt vindicated in my response when, two hours later, the woman herself came onto the verandah to share betel nut and tobacco and to broadcast the story. Her anger was palpable, and she shouted for all to hear her determination to exact a compensation payment from the man. Thinking to obtain information about local women's responses to rape, I began to question her. Had she been frightened? I asked. Of course she had - Wouldn't I feel frightened if I awoke in the dark to find an unknown person inside my mosquito net? Wouldn't I be angry? Why then, I asked,

hadn't she taken the opportunity, while he was entangled in her mosquito net, to kick him hard or to hit him with one of the many wooden implements near at hand? She looked shocked. Why would she do that? she asked - after all, he hadn't hurt her. No, but he had wanted to, I replied. She looked at me with puzzlement. Not able to find a local word for rape in my vocabulary, I scrabbled to explain myself: "He was trying to have sex with you," I said, "although you didn't want to. He was trying to hurt you." She looked at me, more with pity than with puzzlement now, although both were mixed in her expression. "Tin [Christine], it's only a penis," she said. "How can a penis hurt anyone?""

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" About 75% of my aunts / uncles were abused / raped. Around 20% of the boomer friends I have that I’ve had deep conversations with have shared stories with me of them being raped / sexually abused as children. I think the actual real prevalence based on my own experience is probably somewhere between 20%-50%.


This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women. Given that there were then only about one hundred million women living 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."

Taken together, Robert McIntyre seems to be implying 20-50% of boomer women were raped by their immediate family. I won't say I don't believe it, but I will say that extraordinary claims require extraordinary evidence, and this is definitely an extraordinary claim.

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Re Holocaust survivors: here in Israel it's accepted as common knowledge that Holocaust survivors suffer from some type of ongoing trauma response, and moreover that their behavior inflicted trauma on their children. Saying that your parents survived the Holocaust is tantamount to saying that you were traumatized by your parent's response to their Holocaust experience. I'm sure there are studies on this.

Although perhaps the point is that most of the survivors and their children were and are productive member of society and therefore not "disabled"?

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This whole discussion (and review) kind of surprised me, I have to admit, because I always assumed that it was sort of obvious and uncontroversial that all this stuff like anorexia and transsexualism are conversion disorders. Basically, conversion disorders used to be simple, obvious physical things like turning blind or hysteric paralysis, but then we developed tools to test these (e.g. reflex hammers) which showed that they were entirely psychologically induced, so then the disorders gradually shifted toward vague, hard-to prove conditions like anorexia, fibromyalgia and gender dysphoria, where the doctor couldn't just look at your tongue or something and say "nope, no trace of that here, your body is working perfectly normally as we've just proved, so it's all in your head".

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Oh, also: "A second counterargument might be that if Western psychiatry only works because we think it does, we would probably want to know that, and then once we figure it out, it would stop working" – isn't this exactly what you yourself have written about in the past, the mysterious fact that Freudian therapy used to work great, and then it stopped working? And the same thing happened to CBT?

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AskHistorians has a number of answers on ptsd in history, this one could be a starting point: https://www.reddit.com/r/AskHistorians/comments/457idw/did_people_in_ancientmedieval_times_suffer_from/

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"I have a vivid memory of reading a study that basically argued this - victims of child sexual abuse don’t think or care about it much until people tell them that it’s taboo and traumatic, and which point they are duly traumatized - but I can’t find it now. [...]"


"I am sympathetic to this based on an experience I had, where I was pretty bad at tolerating noise, but kind of within the normal human spectrum and never thought much of it, and then I lived with a noisy roommate who characterized my distaste for noise as freakish and psychiatric-level, and after that, every time I heard a noise I started panicking and questioning whether I was going to have some sort of freakish and psychiatric-level reaction to it, and this became so unpleasant that now I do have a freakish and psychiatric-level noise intolerance - or at least this is how I remember it."

This reminded me of my fictional (vaguely anarcho-monarchist) micronation's definition of treason, which in summary was something like "you're committing treason if you systematically attempt to convince people that other people are out to get them". It was seen as a supreme memetic threat, because they considered it so insidiously difficult to disprove and a comfortable thought for the person(/people) who had been declared a victim. How can sudden displeasure be 'comfortable'? Well, if your social circle tells you that you're a victim, they're on some level signalling their desire to protect you, possibly even give you free stuff in apology for the thing that happened to you. It's mentally very tempting to just accept that narrative; that this can result in you feeling emotionally much worse than you previously did doesn't necessarily stop this effect.

That said, this *is* a fictional micronation we're talking about, and the effort that went into world-building was limited to what seemed like a fun thought at the time, so I don't expect this to hold up against any rigorous scrutiny whatsoever. I'm not a psychologist and the way this nation thought about this phenomenon (= that something becomes horrible once people have convinced you that it is a horrible thing), in ascribing it to social convenience for the victim, is almost surely wrong.

What it *does* tell you is that the author (i.e. me) did observe this phenomenon - largely in verself, actually! This happened a few times. The most striking time was when my mum went over my finances with me back when I was studying and convinced me I was actually poor. It was total bullshit (I was comfortable paying rent, eating, and even taking my primary out to restaurants occasionally), but it seemed *really* compelling at the time and I bought it (pun... half intended?) and cried about it. Thankfully I was lucid enough that I also kicked myself out of that false belief a few hours later.

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>A responsible treatment of this would have to discuss the history of traditional societies around the world that have something vaguely similar to our concept of transgender (like “third gender” roles in certain tribes), then move on to transvestism in the 1980s, and come up with some position on how these relate to modern transgender. One interpretation might be that there is some biological substrate for gender nonconformity (eg some evolved part of the brain that is supposed to tell you what gender you are can misfire in some way), and then the way that people feeling vague anxiety about their gender deal with it varies based on the local cultural milieu.

'Traditional society' to '1980s' is missing a few steps, innit?

Anyway, you may find food for thought in the 1918 memoir _Autobiography of an Androgyne_, by "Jennie June". It's not an easy book to read, partly because it describes a depressing amount of abuse, violence, and rape, and partly because the sexual content is all in Latin. But I think it makes a very strong case that sexual nonconformity is both mutable in its expression (as was common at the time, June does not distinguish between 'homosexual' and 'transgender', preferring the term "passive invert"; his life has both features suggestive of modern transgender female identity and strong parallels with modern gay male culture) and fixed in its presence (June suffered pretty much every punishment short of execution for the crime of wanting to consensually suck cock, and yet could not be dissuaded).

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I've commented this elsewhere before, but it baffles me to see someone as otherwise thorough and thoughtful as Scott assert that ADHD is just being on the low end of the bell curve of ability to concentrate. It comes off like he hasn't done any research at all, which is bizarre from a psychiatrist.

ADHD is an entire neurotype, and it has way more symptoms than just "inability to concentrate." There's hyperfocus, hyperfixations, rejection-sensitive dysphoria, and an inverse reaction to stimulants, among others! A non-ADHD person who was just absentminded probably wouldn't fall asleep after three cups of coffee or need to fidget in order to think. There's no such thing as "primarily hyperactive type inability to concentrate."

ADHD is a lot more like autism (of which it's sometimes considered a cousin condition, because their symptoms overlap) than it is like being unusually clumsy or unusually tall. It's like a brain running on Linux instead of Windows. Reducing it to one single trait is inaccurate.

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> I think the evidence strongly suggests that ancient combatants did not experience PTSD as we do now. [...] The more interesting potential question is why. Considering all of the competing theories for that, I think, would take its own collections post. But for my part, I tend to think the difference lies in part on the moral weight placed on warfare

Interesting. My first instinct is that their lives were just so much harder leading up to being a soldier, that they're just better at coping with emotional and physical hardship, and so they don't actually get traumatized.

Consider that by the time a person reaches maturity, they probably would have already lost a few siblings, they were used to slaughtering animals and possibly even killing other people or seeing them hanged, and they're accustomed to very hard physical labour. Their whole life up to that point was trauma resistance training.

We're fairly pampered by comparison, both emotionally and physically. So maybe PTSD partly results from the fact that we're too safe to have built up the necessary resistance to the horrors of war.

> I remember one that clearly made the connection to being traumatized after you’re informed it’s taboo. Does anyone know what I’m thinking of?

I remember reading one about adult female victims that reached a similar conclusion, ie. that they became more traumatized after seeing how horrified other people were over their experience, and only then did the victims feel shame over what happened to them.

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This may seem obvious but I think it's worth saying: it sounds like the presence or lack of childhood trauma as a result of early sexual contact comes down to consent, and I don't see any evidence to convince me that the alternate hypothesis (it's solely a result of parents'/society's expectations or reactions) is remotely tenable (although I can understand how a big dramatic reaction to a non-traumatic event would make the event feel traumatic).

Legal definitions aside, I think most would agree that children are capable of either consenting or not consenting to things. They can be convinced by perpetrators to participate in sexual activity voluntarily, in which case it seems plausible that some would not be traumatized by those experiences until someone makes a big deal out of it much later. Especially if prepubescent sexual activity is culturally acceptable (e.g. Massai culture, at least in Tanzania).

But the existence of individuals who weren't traumatized by early sexual contact does not constitute evidence to support a claim that the enduring distress resulting from childhood sexual abuse is a cultural phenomenon that arises only when the person discovers they violated a taboo. This idea conflicts with every single instance I know of, including my own (I know a lot of women who were assaulted before they ever learned that assault was a thing, and their distress existed before anyone knew enough to react).

The sole concept here that rings true is that our cultural expectations around trauma have the potential to worsen affected children's prospects when it comes to recovery. That, I would believe.

I'm also curious who wrote the mystery paper mentioned above and how they justified it.

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A comment that I'm very surprised no one has yet brought up is the one that linked to this fascinating study showing a high prevalence of PTSD among Turkana warriors. It would seem to strongly support the 'universalist' view that PTSD has occurred at roughly equal rates among combat veterans throughout history.

Note that the study did find that *depressive* PTSD symptoms were significantly less common among the Turkana, which it attributed to different cultural attitudes toward killing in battle. But hypervigilance, nightmares, and flashbacks were actually *more* common among Turkana warriors than contemporary US combat veterans.


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"I didn’t bring up trans issues because I think they’re a better match for another post I hope to write about related issues in the future, but I agree it sounds like an interesting match for something like this - a psychiatric condition which seems to exists at vanishingly low levels until people work to “raise awareness” of it, after which it becomes very common."

I know this is DEFCON 1 level culture war stuff, but there is a radical feminist blog called "culturally bound gender" that talks about exactly what the title says. That includes a whole post on "traditional" non-binary or "two-spirit" genders, and makes a hypothesis that they're doing something very different from what the modern world thinks they are. I'm not an expert in the area and the post doesn't cite sources I could check, but the author has certainly looked into the topic more than I have.

I deliberately won't link to it here, but if you wish, search engines will find it quickly enough.

(For what it's worth, I myself feel like I match some definitions of "trans" and not others, I'd say I have less of a gender identity than a self-identity where gender is not that big of a thing. I found reading the CBG post on the matter helpful rather than hurtful, your experience may vary.)

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This article lists out several source examples describing historical PTSD symptoms. I'm _totally_ open to the hypothesis that telling people their experiences are traumatic makes those experiences traumatic and that could increase incidences of PTSD in modern times, but I'm fairly skeptical that a PTSD-like thing didn't exist.

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The comment on concussion trauma should be qualified by the difference in combat before gunpowder when a head injury would not have been caused by generally locating the head near an explosive event. Head injuries from any source have only recently been studied in parallel with the PTSD category. A simple skateboarding accident for a young person, for example, can have a life-long, debilitating result which may not be well-classified as a syndrome or disorder given the biology and centralized location of the injury but rather may be better-classified as other local and biological injuries, albeit one that does not heal in the same way.

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Re ptsd

First hit on search term "Homer ptsd"


The Epic of Gilgamesh, one of the first pieces of literature extant and dating back to the third millennium Mesopotamian kingdom of Sumer, details the adventures of the Sumerian king, Gilgamesh, and his warrior companion, Enkidu (Birmes, Hatton, Brunet & Schmitt, 2003). The parallel between Gilgamesh’s post-combat experience and those of modern veterans with the “numbing” and “dissociative” aspects of the modern PTSD diagnosis is striking. On witnessing Enkidu’s death in battle, Gilgamesh is beset by recurrent and intrusive recollections of his friend’s death. A once proud and valiant warrior, Gilgamesh is haunted by these dreams and wanders numb through his kingdom, rendered incapable of regaining his once unassailable martial prowess.

Likewise, in Homer’s Iliad (850 B.C.), the immortal Greek hero, Achilles, is tormented by recurrent nightmares of battle, the death of his companion, Patroclus, and visits in his dreams from the hundreds of men slain by him in combat (Shay, 1994). The impact of these recurrent traumatic dreams and fragmented sleep, which are today recognized symptoms of PTSD, devastated even the great Achilles.

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Comparing my friend circles in Poland and larger US-centric communities on Discords I frequent, people from the US seem very focused on their fragile mental health. Might be all sorts of selection effects, of course.

There's also some kind of huge doom wave sweeping over the internet over recent years, where saying anything optimistic seems almost out of place... I'm worried that the world is becoming an echo chamber where suffering people amplify other people's suffering and the only way to stay sane is to disconnect from the narrative as much as possible. In fact, that is what most of my friends I'd consider mentally stable are already doing!

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Re: Ivan's comment on PTSD claims among recent veterans. It would be a mistake to not attribute the vast portion of those claims to "malingering". Well, not malingering so much as following obvious incentives in an arguably fraudulent (but easy to justify) manner.

You have to understand that these 45% of vets making these claims are not all people making claims of total disability. They are people who are filing claims because both while you are still in the military and especially with respect to your pension when you retire, you are paid extra for any combat damage. Claiming to have more damage literally results in more money in your paycheck. So the incentive is obvious.

My husband retired last year after 25 years in the military. He has been on many combat tours in the Middle East and has been "blown up", as they say, a few times. He does not have PTSD. He does have damage that required surgery to his spine and wrist from explosions. Retirement from the military is a very lengthy process where you go through a bunch of medical and mental exams and do all kinds of paperwork and how much you will be paid each month on your life-long pension is determined partially based on how much physical/emotional damage you have incurred.

While he was going through the process, ALL of his veteran buddies were constantly calling him and giving him advice on all the ways he could maximize his pension by playing up little problems and claiming to have various medical issues. They advised him to get a sleep study and claim to have sleep apnea. They had all kinds of advice. This is a game that they all play to see how much they can ramp up their pensions. He was not willing to fraudulently pretend he had any problems that he doesn't have, though frankly, he was left feeling somewhat like a sucker when his other retired friends laughed at him and told him how much they were being paid for their "PTSD" and sleep apnea and stuff like that.

The incentives are there for soldiers to say they have problems, and PTSD is a lot easier to fake than most other medical issues. So I would look at that 45% figure with extreme suspicion. Obviously no one is going to admit this, or they would get in a lot of trouble. But I witnessed plenty of these conversations ,and it seems like SOP is to exaggerate every "disability" one can, to maximize one's pension. I would be curious to know what year it was that the military started paying extra money to soldiers with PTSD, and my prediction is that you will see a rapid rise in such claims once the monetary incentive was there.

I think if we look at many other types of apparent trauma and mental illness, we will see similar incentives for one to obtain a diagnosis. Everything from extra time to take tests to getting out of class to obtaining sympathy and deference from peers. I don't know exactly what all the incentives are, but clearly there are some major ones among young women/teenagers these days, because they all seem to be off the rails in competing with each other to be the most traumatized and disabled.

Some of the conversations I see on social media amongst them are truly bizarre and there is very obviously a social status system whereby being the most "disabled" confers the highest status. I was once shouted out of a forum by hundreds of hysterical, furious young women for suggesting that being literally blind or having no legs because they were blown off in a war was a relatively worse disability, and more warranted of having a service dog for assistance, than having social anxiety. Apparently that statement is "ablist" and "toxic" and equivalent to attending KKK rallies. Now, to my mind, it is morally reprehensible and one should be ashamed to act as if social anxiety is equally worthy of social resources and sympathy as someone having no legs because they were blown off in combat. How self-pitying can you get?? But that idea was unthinkable and way out of bounds to these young women, who consider every "disability" to be exactly as serious as every other.

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I think this stuff about PTSD relates to an even larger point. I feel like there's a certain psychological defense mechanism that we've eschewed as a society in the West - a sort of denial or suppression or diversion which says "Yes, this isn't pleasant, I'll suck it up and not think about it very much."

Instead we've accepted the dual tenets that:

1) *Fragility*. Any kind of harmful thing (traumatic experience, injury, or in the extreme: verbal offense, feeling of unease, being outside your comfort zone) will cause psychological damage. This is why there are calls to limit speech, not use certain non-PC words, have safe spaces, shield children from playing outside alone, etc.

2) *Active Treatment*. The cure to these psychological damages is not ignoring them and keeping busy with other things, but instead carefully opening the wound (delicately) and trying to disinfect it. We are less inclined to say "Yeah, break-up is difficult, get a job and keep busy. Then pick yourself up and start dating again." Instead we ecourage people to mourn, become aware of their feelings and needs, and so on. I feel like my parents' generation were much more inclined to not reveal their feelings and just move on.

For PTSD there is growing evidence that both of these are false and harmful. But this might be harmful in other domains as well.

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