In the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual Mental Disorders, published in 1952, emotional trauma was completely absent. Andrew Scull (2023), who has studied trauma as a kind of “fashion,” has detailed the long process through which it became so important to American psychiatry. Chaim Shatan (1972) of New York University invented the term post-Vietnam syndrome to refer to delayed appearance of distressing emotional symptoms in soldiers who had fought there. Robert Lifton of Harvard insisted that the symptoms of psychological damage afflicting soldiers could emerge many years later after such an injury. Their advocacy produced the inclusion of posttraumatic stress disorder (PTSD) by the APA as a diagnostic category in 1980, which has kept increasing in importance through to the present day. This disorder is characterized by symptoms such as involuntary recurrent distressing memories, hypervigilance, emotional numbing, rage attacks, and violent behaviors. During past decades, the genesis of trauma’s multiple symptoms has been attributed to all sorts of major and minor psychological wounds. Despite the alleged etiological origins in biology and neurology, pharmacological treatments have had a high failure rate (Hoskins 2015).

Particular attention during recent years has been devoted to soldiers and war victims, leading to dozens of published books. The 2014 New York Times bestseller The Body Keeps the Score by Bessel A. van der Kolk has sold 300 million copies throughout the Western world. Rape and violence survivors constitute another current large clinical population. Judith Herman’s comprehensive book Truth and Repair (2023) is an important book emphasizing emotional trauma for women. Trauma treatment expenses in the United States alone approach $10 billion per year.

Let’s look into The Body Keeps the Score as a prime example of the literature on trauma. It is not surprising the book, full of allusions to English and world literature and packed with imaginative cures for all varieties of trauma and referring to impressive neurobiology findings, has been widely read. It contains an astonishingly large number of pertinent and valuable citations—twenty-five of which refer to van der Kolk’s own original research.

But many flaws and unsupported guesswork weaken the value of the book. Readers of this now-famous nonfiction work, which is experiencing a resurgence in popularity, need to be wary of its assertions, conclusions, and recommendations. As a skeptical psychiatrist, I will attempt to highlight the many errors and weaknesses of the book’s many unsupported allegations. Before I confront some of the more substantial claims in The Body Keeps the Score, let me first present a sampling of the book’s claims related to the many approaches and remedies for the painful consequences of trauma.

Traditional Freudian reliving of traumatic events is generally considered a therapeutic failure, but traditional psychoanalytic approaches pioneered by Freud, Breuer, Janet, and Charcot are described as useful. Prozac and similar SSRI agents are considered effective while antipsychotic drugs are considered questionable. Van der Kolk is skeptical about the worth of benzodiazepines but values highly the use of MDMA (ecstasy). Neurofeedback and acupuncture are described as effective. He claims behavioral desensitization to traumatic memories may be helpful and considers somatic therapies quite valuable. Breathing, calming practices, mindfulness, hypnosis, caring for animals, rhythmic chanting and dancing, and being touched and hugged are all described in the book as being beneficial. Van der Kolk also claims that acting and live theater activities assist the treatment of a vast array of earlier traumatic experiences. Overall, the author’s recommendations represent a mix of supported and unsupported claims. Now that you have a sense of the broad range of claims in the book, I will focus in more detail on two claimed treatments for trauma in the book: EMDR and yoga.

Chapter 15 of The Body Keeps the Score (“Letting Go of the Past: EMDR”) includes the case history of “David” and the treatment approach called eye movement desensitization reprocessing (EMDR). David had a long history of drug addiction, which illustrates the imprecision of the PTSD diagnosis. “Maggie” is another case history involving drug addiction. In another one of the book’s case studies, “Kathy” indicates that “The process freed something in her mind/brain to activate new images, feelings and thoughts” (261). What that “something” is (or was) remains a mystery. All these single case studies suffer from the same problem. If data are derived from changes in personality traits of a single human being, then extensive use of that record of change requires initial skepticism. There is much more strength in data that have been obtained from hundreds of human participants or more.

Van der Kolk calls EMDR a “scientific advance” (253), a claim that remains unsupported today. Yes, many of its findings have been reproduced in public experiments, but most of these contain faulty research methods. Its inventor, Francine Shapiro, author of the 2004 book EMDR: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress, and Trauma, did not expose her method to adequate experimentation. She did not utilize well-designed randomized controlled trials. Likewise, van der Kolk used only eighty-eight volunteers in his study comparing brief EMDR, Prozac, and placebo (van der Kolk et al. 2007). No treatment produced complete symptom remission, and Prozac was about as successful a treatment as EMDR. Using his understanding of the brain, van der Kolk stated, “On their scans we could see a sharp increase in prefrontal lobe activation after treatment as well as much more activity in the anterior cingulate and the basal ganglia” (256). This finding neither was reproduced nor allows for any cause-and-effect explanation.

Considerable research published over a decade ago casts further doubt on EMDR’s beneficial findings and its incredible array of effectiveness explanations. “Fixed eye movement conditions in which subjects fix their eyes forward made no difference in treatment outcomes” (Arkowitz and Lilienfeld 2012). (For a more detailed critique of EMDR, see Gerald Rosen and Loren Pankratz’s article in this issue, “Eye Movement Therapies, Purple Hats, and the Sagan Standard,” on p. 54.)

Chapter 16 (“Learning to Inhabit Your Body: Yoga”) opens with a beautiful quotation from Stephen Cope’s 1999 book Yoga and the Quest for the True Self. The quote refers to a “visceral reconnection with the needs of our bodies” that supposedly fosters “a capacity to love the self.” This idea originated in his widely read book about yoga. Cope was known as an esoteric yoga teacher who lacked any scientific credentials. A case history of “Annie,” who had been abused by her parents as a child, opens the chapter. Annie engaged in self-cutting and repeatedly entered psychiatric hospitals. Van der Kolk treated her by using focused breathing and acupressure as part of the emotional freedom technique (EFT), an approach that lacks a reference in the book. Supposedly, her amygdala neurological structure needed “rewiring.” EFT suffers from many of the same research weaknesses as EMDR.

Van der Kolk admits that half of traumatized patients use drugs or alcohol to numb themselves, but the book tends to ignore addiction treatments. A likely incorrect statement follows: “lack of coherence between breathing and heart rate makes persons vulnerable” to heart disease, cancer, and depression. People with PTSD are said to have unusually low heart rate variability (HRV), and van der Kolk states that “their sympathetic and parasympathetic nervous systems are out of sync” (269). The cited reference to James W. Hopper et al. (2006) and Herman’s Truth and Repair begins with two words of caution, “Preliminary Evidence,” but allusions to this work then occupies several more pages. Surprising is the author’s odd statement that while Google lists 17,000 yoga sites claiming that the practice improves HRV, he could find no supporting studies. Nevertheless, Van der Kolk became a teacher at a yoga center while claiming that his own HRV had improved. Such a truth claim resembles a sophisticated advertisement.

The chapter also mentions, without a supporting citation, that in van der Kolk’s study of six women during twenty weeks of yoga practice, there was “increased activation of the basic self-system, the insula and the medial prefrontal cortex.” However, his claim lacks a plausible cause-effect explanation or even a proposal for a likely mechanism of action. The chapter ends optimistically with Annie and her husband happily “cuddled together in bed.” Love reigns supreme, and beneficiaries of odd treatments hardly need worry about proof of effectiveness.

The Body Keeps the Score, while eloquently written, is scientifically weak, misleading, flawed, and at times deceptive. It relies on fascinating clinical anecdotes and references to the finest literature of the western world. Also, it exploits a spurious connection to contemporary neuroscience. It is a prime example of dubious scientific literature.

References

Arkowitz, H., and S. Lilienfeld. 2012. EMDR: Taking a closer look. Scientific American (August 1). Online at https://www.scientificamerican.com/article/emdr-taking-a-closer-look/.

Herman, Judith. 2023. Truth and Repair: How Trauma Survivors Envision Justice. New York, NY: Basic Books.

Hopper, James W., Joseph Spinazzola, William B. Simpson, et al. 2006. Preliminary evidence of parasympathetic influence in basal heart rate in posttraumatic stress disorder. Journal of Psychosomatic Research 60(1): 83–90.

Hoskins, Mathew. 2015. Pharmacotherapy for post-traumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry 206(2) 93–100.

Scull, Andrew. 2023. The fashions in trauma. Liberties 3(2): 171–191.

Shapiro, Francine. 2004. EMDR: The Breakthrough Eye Movement Therapy for Overcoming Anxiety, Stress, and Trauma. New York, NY: Basic Books.

Shatan, Chaim F. 1972. Post-Vietnam syndrome. New York Times (May 6).

Van der Kolk, Bessel A., et al. 2007. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine and pill placebo in the treatment of posttraumatic stress disorder: Treatment effects and long term maintenance. Journal of Clinical Psychiatry 68(1): 37–46.