Less Wrong is a community blog devoted to refining the art of human rationality. Please visit our About page for more information.
It’s time for a new survey!
I posted a few weeks back asking for suggestions for questions to include on the survey. As much as we’d like to include more of them, we all know what happens when we have too many questions. The following graph is from the last survey.
(Source: JD’s analysis of 2014 survey data)
Two factors seem to predict if a question will get an answer:
Whether people want to answer it. (Obviously)
People answer fewer questions as we approach the end. They also skip tricky questions. The least answered question on the last survey was - “what is your favourite lw post, provide a link”. Which I assume was mostly skipped for the amount of effort required either in generating a favourite or in finding a link to it. The second most skipped questions were the digit-ratio questions which require more work, (get out a ruler and measure) compared to the others. This is unsurprising.
This year’s survey is almost the same size as the last one (though just a wee bit smaller). Preliminary estimates suggest you should put aside 25 minutes to take the survey, however you can pause at any time and come back to the survey when you have more time. If you’re interested in helping process the survey data please speak up either in a comment or a PM.
We’re focusing this year particularly on getting a glimpse of the size and shape of the LessWrong diaspora. With that in mind; if possible - please make sure that your friends (who might be less connected but still hang around in associated circles) get a chance to see that the survey exists; and if you’re up to it - encourage them to fill out a copy of the survey.
The survey is hosted and managed by the team at FortForecast, you’ll be hearing more from them soon. The survey can be accessed through http://lesswrong.com/2016survey.
Survey responses are anonymous in that you’re not asked for your name. At the end we plan to do an opt-in public dump of the data. Before publication the row order will be scrambled, datestamps, IP addresses and any other non-survey question information will be stripped, and certain questions which are marked private such as the (optional) sign up for our mailing list will not be included. It helps the most if you say yes but we can understand if you don’t.
Thanks to Namespace (JD) and the FortForecast team, the Slack, the #lesswrong IRC on freenode, and everyone else who offered help in putting the survey together, special thanks to Scott Alexander whose 2014 survey was the foundation for this one.
When answering the survey, I ask you be helpful with the format of your answers if you want them to be useful. For example if a question asks for an number, please reply with “4” not “four”. Going by the last survey we may very well get thousands of responses and cleaning them all by hand will cost a fortune on mechanical turk. (And that’s for the ones we can put on mechanical turk!) Thanks for your consideration.
The survey will be open until the 1st of may 2016
Addendum from JD at FortForecast: During user testing we’ve encountered reports of an error some users get when they try to take the survey which erroneously reports that our database is down. We think we’ve finally stamped it out but this particular bug has proven resilient. If you get this error and still want to take the survey here are the steps to mitigate it:
Refresh the survey, it will still be broken. You should see a screen with question titles but no questions.
Press the “Exit and clear survey” button, this will reset your survey responses and allow you to try again fresh.
Rinse and repeat until you manage to successfully answer the first two questions and move on. It usually doesn’t take more than one or two tries. We haven’t received reports of the bug occurring past this stage.
If you encounter this please mail firstname.lastname@example.org with details. Screenshots would be appreciated but if you don’t have the time just copy and paste the error message you get into the email.
Meta - this took 2 hours to write and was reviewed by the slack.
My Table of contents can be found here.
I have been thinking for a while that it would be useful if there was something similar to the Less Wrong Canon on Rationality for the CFAR material. Maybe, it could be called the 'CFAR Canon on Applied Rationality'. To start on this I have compiled a collection of descriptions for the CFAR techniques that I could find. I have separated the techniques into a few different sections. The sections and descriptions have mostly been written by me, with a lot of borrowing from other material, which means that they may not accurately reflect what CFAR actually teaches.
Please note that I have not attended any CFAR workshops, nor am I affiliated with CFAR in any way. My understanding of these techniques comes from CFAR videos, blogs and other websites which I have provided links to. If I have missed any important techniques or if my understanding of any of the techniques is incorrect or if you can provide links to the research that these techniques are based on, please let me know and I will update this post.
Learning this material based solely on the descriptions written here may be unhelpful, arduous or even harmful. (See Duncan_Sabien's full comment for more information on this) It is because the material is very hard to learn correctly. Most of the techniques below involve in one way or another volitionally overriding your instinctual, intuitive or ingrained behaviours and thoughts. These are thoughts which not only often feel enticing and alluring, but that also often feel unmistakably right. If you are anything like me, then you should be very careful if you are trying to learn this material alone. For you will be prone to rationalization, taking shortcuts and making mistakes.
My recommendations for trying to learn this material are:
- learn it deeply and be sure to put what you have learnt into practice. It will often help if you take notes on what works for you and what doesn't. Also take note of the 'Mindsets and perspectives that help you in discovering potential situations that you could end up valuing' section as these are very important.
- get the help of experts or other people who have already expended great amounts of effort in trying to implement this material like the people at cfar. This will save you a great amount of stress and effort as it will allow you to avoid a plethora of potential mistakes and inefficiencies. If you really want to learn this material, then you should deeply consider attending a CFAR workshop.
- get the help of or involve friends. As Duncan_Sabien has said:
It is better on almost every axis with instructors, mentors, friends, companions—people to help you avoid the biggest pitfalls, help you understand the subtle points, tease apart the interesting implications, shore up your motivation, assist you in seeing your own mistakes and weaknesses. None of that is impossible on your own, but it's somewhere between one and two orders of magnitude more efficient and more efficacious with guidance".
- be dubious of your mental models. Beware thoughts and ideas that feel unequivocally right especially if they are solely located internally rather than also being expressed or formulated externally.
- You might want to bookmark this page instead of reading it all at once as it is quite long.
Recently, multiple suspicious user accounts were created on Less Wrong. These accounts don't post any content in the forum. Instead, they are used only to send private messages to the existing users.
Many users have received a copy of the same message, but different variants exist, too. Here are the examples I know about. If you have received a different variant, please post it in a comment below this article:
Hi good day. My boss is interested on donating to MIRI's project and he is wondering if he could send money through you and you donate to miri through your company and thus accelertaing the value created. He wants to use "match donations" as a way of donating thats why he is looking for people in companies like you. I want to discuss more about this so if you could see this message please give me a reply. Thank you!
I don't know yet about anyone who replied and got scammed, so this is all based on indirect evidence. If you got scammed, please tell me. If you are ashamed, I can publish your story anonymously. Your story could help other potential victims.
Most likely, the scheme is the following:
- The scammer will send you money.
- Then they will ask some of the money back because they changed their mind, or they mistakenly sent you more than they wanted, or their financial situation suddenly changed, or whatever.
- After receiving the money from you, they will flag the original transaction as a fraud, so they get back the money they originally sent you, plus the money you sent them back. Then they disappear, or it will turn out they used a stolen identity, etc.
If you replied to the original message and now you are already in the middle of the process, please inform your bank as soon as possible! Even if the step 2 didn't happen yet, so you can still get out without losing money, warning your bank about the scammer could help other potential victims.
Warning: If you have already received a check or a payment confirmation, and someone is asking you to send the overpayment back quickly, do not send anything. The check or the payment confirmation is fake, and the goal is to make you send money before you find out. (Thanks to
- Chronic Fatigue and Fibromyalgia look very like Hypothyroidism.
- Thyroid Patients aren't happy with either the diagnosis or treatment of Hypothyroidism.
- It is possible that lots of FMS/CFS cases are 'something wrong with the thyroid system that doesn't show up on laboratory hormone level tests'.
- It's possible that it's not too difficult to fix these CFS/FMS cases with thyroid hormones.
- I believe that there may have been a stupendous cock-up that's hurt millions.
- Less Wrong should be interested, because it could be a real example of how bad inference can cause the sciences to come to false conclusions, as well as a good practice problem for the things we really care about.
I found a possible answer here:
I do not believe it, because I do not understand it, but contemplation of it seems to be enlightening. In particular, the problem is much broader than I originally thought.
A summary of the argument in the first two posts, together with links to lots of evidence in the literature:
And this is pretty much proof, I think:
At this point, I think I'm as confident as I can be without some sort of formal trial (so 25% maybe?)
But certainly, if you're suffering from Chronic Fatigue Syndrome/Fibromyalgia/Major Depression/Irritable Bowel Syndrome, or any of the many similar disorders which just seem to be different names for 'hypothyroidism with normal TSH', I reckon this is worth trying!
I have done, and it worked for me. For about four months now...
I believe that I've come across a genuine puzzle, and I wonder if you can help me solve it. This problem is complicated, and subtle, and has confounded and defeated good people for forty years. And yet there are huge and obvious clues. No-one seems to have conducted the simple experiments which the clues suggest, even though many clever people have thought hard about it, and the answer to the problem would be very valuable. And so I wonder what it is that I am missing.
I am going to tell a story which rather extravagantly privileges a hypothesis that I have concocted from many different sources, but a large part of it is from the work of the late Doctor John C Lowe, an American chiropractor who claimed that he could cure Fibromyalgia.
I myself am drowning in confirmation bias to the point where I doubt my own sanity. Every time I look for evidence to disconfirm my hypothesis, I find only new reasons to believe. But I am utterly unqualified to judge. Three months ago I didn't know what an amino acid was. And so I appeal to wiser heads for help.
Crocker's Rules on this. I suspect that I am being the most spectacular fool, but I can't see why, and I'd like to know.
Setting the Scene
Chronic Fatigue Syndrome, Myalgic Encephalitis, and Fibromyalgia are 'new diseases'. There is considerable dispute as to whether they even exist, and if so how to diagnose them. They all seem to have a large number of possible symptoms, and in any given case, these symptoms may or may not occur with varying severity.
As far as I can tell, if someone claims that they're 'Tired All The Time', then a competent doctor will first of all check that they're getting enough sleep and are not unduly stressed, then rule out all of the known diseases that cause fatigue (there are a very lot!), and finally diagnose one of the three 'by exclusion', which means that there doesn't appear to be anything wrong, except that you're ill.
If widespread pain is one of the symptoms, it's Fibromyalgia Syndrome (FMS). If there's no pain, then it's CFS or ME. These may or may not be the same thing, but Myalgic Encephalitis is preferred by patients because it's greek and so sounds like a disease. Unfortunately Myalgic Encephalitis means 'hurty muscles brain inflammation', and if one had hurty muscles, it would be Fibromyalgia, and if one had brain inflammation, it would be something else entirely.
Despite the widespread belief that these are 'somatoform' diseases (all in the mind), the severity of them ranges from relatively mild (tired all the time, can't think straight), to devastating (wheelchair bound, can't leave the house, can't open one eye because the pain is too great).
All three seem to have come spontaneously into existence in the 1970s, and yet searches for the responsible infective agent have proved fruitless. Neither have palliative measures been discovered, apart from the tried and true method of telling the sufferers that it's all in their heads.
The only treatments that have proved effective are Cognitive Behavioural Therapy / Graded Exercise. A Cochrane Review reckoned that they do around 15% over placebo in producing a measurable alleviation of symptoms. I'm not very impressed. CBT/GE sound a lot like 'sports coaching', and I'm pretty sure that if we thought of 'Not Being Very Good at Rowing' as a somatoform disorder, then I could produce an improvement over placebo in a measurable outcome in ten percent of my victims without too much trouble.
But any book on CFS will tell you that the disease was well known to the Victorians, under the name of neurasthenia. The hypothesis that God lifted the curse of neurasthenia from the people of the Earth as a reward for their courage during the wars of the early twentieth century, while well supported by the clinical evidence, has a low prior probability.
We face therefore something of a mystery, and in the traditional manner of my people, a mystery requires a Just-So Story:
How It Was In The Beginning
In the dark days of Victoria, the brilliant physician William Miller Ord noticed large numbers of mainly female patients suffering from late-onset cretinism.
These patients, exhausted, tired, stupid, sad, cold, fat and emotional, declined steeply, and invariably died.
As any man of decent curiosity would, Dr Ord cut their corpses apart, and in the midst of the carnage noticed that the thyroid, a small butterfly-shaped gland in the throat, was wasted and shrunken.
One imagines that he may have thought to himself: "What has killed them may cure them."
After a few false starts and a brilliant shot in the dark by the brave George Redmayne Murray, Dr Ord secured a supply of animal thyroid glands (cheaply available at any butcher, sautée with nutmeg and basil) and fed them to his remaining patients, who were presumably by this time too weak to resist.
They recovered miraculously, and completely.
I'm not sure why Dr Ord isn't better known, since this appears to have been the first time in recorded history that something a doctor did had a positive effect.
Dr Ord's syndrome was named Ord's Thyroiditis, and it is now known to be an autoimmune disease where the patient's own antibodies attack and destroy the thyroid gland. In Ord's thyroiditis, there is no goiter.
A similar disease, where the thyroid swells to form a disfiguring deformity of the neck (goiter), was described by Hakaru Hashimoto in 1912 (who rather charmingly published in German), and as part of the war reparations of 1946 it was decided to confuse the two diseases under the single name of Hashimoto's Thyroiditis. Apart from the goiter, both conditions share a characteristic set of symptoms, and were easily treated with animal thyroid gland, with no complications.
Many years before, in 1835, a fourth physician, Robert James Graves, had described a different syndrome, now known as Graves' Disease, which has as its characteristic symptoms irritability, muscle weakness, sleeping problems, a fast heartbeat, poor tolerance of heat, diarrhoea, and weight loss. Unfortunately Dr Graves could not think how to cure his eponymous horror, and so the disease is still named after him.
The Horror Spreads
Victorian medicine being what it was, we can assume that animal glands were sprayed over and into any wealthy person unwise enough to be remotely ill in the vicinity of a doctor. I seem to remember a number of jokes about "monkey glands" in PG Wodehouse, and indeed a man might be tempted to assume that chimpanzee parts would be a good substitute for humans. Supply issues seem to have limited monkey glands to a few millionaires worried about impotence, and it may be that the corresponding procedure inflicted on their wives has come down to us as Hormone Replacement Therapy.
Certainly anyone looking a bit cold, tired, fat, stupid, sad or emotional is going to have been eating thyroids. We can assume that in a certain number of cases, this was just the thing, and I think it may also be safe to assume that a fair number of people who had nothing wrong with them at all died as a result of treatment, although the fact that animal thyroid is still part of the human food chain suggests it can't be that dangerous.
I mean seriously, these people use high pressure hoses to recover the last scraps of meat from the floors of slaughterhouses, they're not going to carefully remove all the nasty gristly throat-bits before they make ready meals, are they?
The Armour Sausage company, owner of extensive meat-packing facilities in Chicago, Illinois, and thus in possession of a large number of pig thyroids which, if not quite surplus to requirements, at the very least faced a market sluggish to non-existent as foodstuffs, brilliantly decided to sell them in freeze-dried form as a cure for whatever ails you.
Some Sort of Sanity Emerges, in a Decade not Noted for its Sanity
Around the time of the second world war, doctors became interested in whether their treatments actually helped, and an effort was made to determine what was going on with thyroids and the constellation of sadness that I will henceforth call 'hypometabolism', which is the set of symptoms associated with Ord's thyroiditis. Jumping the gun a little, I shall also define 'hypermetabolism' as the set of symptoms associated with Graves' disease.
The thyroid gland appeared to be some sort of metabolic regulator, in some ways analogous to a thermostat. In hypometabolism, every system of the body is running slow, and so it produces a vast range of bad effects, affecting almost every organ. Different sufferers can have very different symptoms, and so diagnosis is very difficult.
Dr Broda Barnes decided that the key symptom of hypometabolism was a low core body temperature. By careful experiment he established that in patients with no symptoms of hypometabolism the average temperature of the armpit on waking was 98 degrees Fahrenheit (or 36.6 Celsius). He believed that temperature variation of +/- 0.2 degrees Fahrenheit was unusual enough to merit diagnosis. He also seems to have believed, in the manner of the proverbial man with a hammer, that all human ailments without exception were caused by hypometabolism, and to have given freeze-dried thyroid to almost everyone he came into contact with, to see if it helped. A true scientist. Doctor Barnes became convinced that fully 40% of the population of America suffered from hypometabolism, and recommended Armour's Freeze Dried Pig Thyroid to cure America's ills.
In a brilliant stroke, Freeze Dried Pig's Thyroid was renamed 'Natural Desiccated Thyroid', which almost sounds like the sort of thing you might take in sound mind. I love marketing. It's so clever.
America being infested with religious lunatics, and Chicago being infested with nasty useless gristly bits of cow's throat, led almost inevitably to a second form of 'Natural Desiccated Thyroid' on the market.
Dr Barnes' hypometabolism test never seems to have caught on. There are several ways your temperature can go outside his 'normal' range, including fever (too hot), starvation (too cold), alcohol (too hot), sleeping under too many duvets (too hot), sleeping under too few duvets (too cold). Also mercury thermometers are a complete pain in the neck, and take ten minutes to get a sensible reading, which is a long time to lie around in bed carefully doing nothing so that you don't inadvertently raise your body temperature. To make the situation even worse, while men's temperature is reasonably constant, the body temperature of healthy young women goes up and down like the Assyrian Empire.
Several other tests were proposed. One of the most interesting is the speed of the Achilles Tendon Reflex, which is apparently super-fast in hypermetabolism, and either weirdly slow or has a freaky pause in it if you're running a bit cold. Drawbacks of this test include 'It's completely subjective, give me something with numbers in it', and 'I don't seem to have one, where am I supposed to tap the hammer-thing again?'.
By this time, neurasthenia was no longer a thing. In the same way that spiritualism was no longer a thing, and the British Empire was no longer a thing.
As far as we know, Chronic Fatigue Syndrome was not a thing either, and neither was Fibromyalgia (which is just Chronic Fatigue Syndrome but it hurts), nor Myalgic Encephalitis. There was something called 'Myalgic Neurasthenia' in 1934, but it seems to have been a painful infectious disease and they thought it was polio.
It turned out that the purpose of the thyroid gland is to make hormones which control the metabolism. It takes in the amino acid tyrosine, and it takes in iodine. It releases Thyroglobulin, mono-iodo-tyrosine (MIT), di-iodo-tyrosine (DIT), thyroxine (T4) and triiodothyronine (T3) into the blood. The chemistry is interesting but too complicated to explain in a just-so story.
I believe that we currently think that thyroglobulin, MIT and DIT are simply by-products of the process that makes T3 and T4.
T3 is the hormone. It seems to control the rate of metabolism in all cells. T4 has something of the same effect, but is much less active, and called a 'prohormone'. Its main purpose seems to be to be deiodinated to make more T3. This happens outside the thyroid gland, in the other parts of the body ('peripheral conversion'). I believe mainly in the liver, but to some extent in all cells.
Our forefathers knew about thyroxine (T4, or thyronine-with-four-iodines-attached), and triiodothyronine (T3, or thyronine-with-three-iodines-attached)
It seems to me that just from the names, thyroxine was the first one to be discovered. But I'm not sure about that. You try finding a history-of-endocrinology website. At any rate they seem to have known about T4 and T3 fairly early on.
The mystery of Graves', Ord's and Hashimoto's thyroid diseases was explained.
Ord's and Hashimoto's are diseases where the thryoid gland under-produces (hypothyroidism). The metabolism of all cells slows down. As might be expected, this causes a huge number of effects, which seem to manifest differently in different sufferers.
Graves' disease is caused by the thyroid gland over-producing (hyperthyroidism). The metabolism of all cells speeds up. Again, there are a lot of possible symptoms.
All three are thought to be autoimmune diseases. Some people think that they may be different manifestations of the same disease. They are all fairly common.
Desiccated thryoid cures hypothyroidism because the ground-up thyroids contain T4 and T3, as well as lots of thyroglobulin, MIT and DIT, and they are absorbed by the stomach. They get into the blood and speed up the metabolism of all cells. By titrating the dose carefully you can restore roughly the correct levels of the thyroid hormones in all tissues, and the patient gets better. (Titration is where you change something carefully until you get it right)
The theory has considerable explanatory power. It explains cretinism, which is caused either by a genetic disease, or by iodine deficiency in childhood. If you grow up in an iodine deficient area, then your growth is stunted, your brain doesn't develop properly, and your thyroid gland may become hugely enlarged. Presumably because the brain is desperately trying to get it to produce more thyroid hormones, and it responds by swelling.
Once upon a time, this swelling (goitre) was called 'Derbyshire Neck'. I grew up near Derbyshire, and I remember an old rhyme: "Derbyshire born, Derbyshire bred, strong in the arm, and weak in the head". I always thought it was just an insult. Maybe not. Cretinism was also popular in the Alps, and there is a story of an English traveller in Switzerland of whom it was remarked that he would have been quite handsome if only he had had a goitre. So it must have been very common there.
But at this point I am *extremely suspicious*. The thyroid/metabolic regulation system is ancient (universal in vertebrates, I believe), crucial to life, and it really shouldn't just go wrong. We should suspect either an infectious cause, or a recent environmental influence which we haven't had time to adjust to, an evolved defence against an infectious disease, or just possibly, a recently evolved but as yet imperfect defence against a less recent environmental change.
(Cretinism in particular is very strange. Presumably animals in iodine-deficient areas aren't cretinous, and yet they should be. Perhaps a change to a farming from a hunter-gatherer lifestyle has increased our dependency on iodine from crops, which crops have sucked what little iodine occurs naturally out of the soil?)
It's also not entirely clear to me what the thyroid system is *for*. If there's just a particular rate that cells are supposed to run at, then why do they need a control signal to tell them that? I could believe that it was a literal thermostat, designed to keep the body temperature constant at the best speed for the various biological reactions, but it's universal in *vertebrates*. There are plenty of vertebrates which don't keep a constant temperature.
The Fall of Desiccated Thyroid
There turned out to be some problems with Natural Desiccated Thyroid (NDT).
Firstly, there were many competing brands and types, and even if you stuck to one brand the quality control wasn't great, so the dose you'd be taking would have been a bit variable.
Secondly, it's fucking pig's thyroid from an abattoir. It could have all sorts of nasty things in it. Also, ick.
Thirdly, it turned out that pigs made quite a lot more T3 in their thyroids than humans do. It also seems that T3 is better absorbed by the gut than T4 is, so someone taking NDT to compensate for their own underproduction will have too much of the active hormone compared to the prohormone. That may not be good news.
With the discovery of 'peripheral conversion', and the possibility of cheap clean synthesis, it was decided that modern scientific thyroid treatment would henceforth be by synthetic T4 (thyroxine) alone. The body would make its own T3 from the T4 supply.
Alarm bells should be ringing at this point. Apart from the above points, I'm not aware of any great reason for the switch from NDT to thyroxine in the treatment of hypothyroidism, but it seems to have been pretty much universal, and it seems to have worked.
Aware of the lack of T3, doctors compensated by giving people more T4 than was in their pig-thyroid doses. And there don't seem to have been any complaints.
Over the years, NDT seems to have become a crazy fringe treatment despite there not being any evidence against it. It's still a legal prescription drug, but in America it's only prescribed by eccentrics. In England a doctor prescribing it would be, at the very least, summoned to explain himself before the GMC.
However, since it was (a) sold over the counter for so many years, and (b) part of the food chain, it is still perfectly legal to sell as a food supplement in both countries, as long as you don't make any medical claims for it. And the internet being what it is, the prescription-only synthetic hormones T3 and T4 are easily obtained without a prescription. These are extremely powerful hormones which have an effect on metabolism. If 'body-builders' and sports cheats aren't consuming all three in vast quantities, I am a Dutchman.
The Clinical Diagnosis of Hypothyroidism
We pass now to the beginning of the 1970s.
Hypothyroidism is ferociously difficult to diagnose. People complain of 'Tired All The Time' well, ... all the time, and it has literally hundreds of causes.
And it must be diagnosed correctly! If you miss a case of hypothyroidism, your patient is likely to collapse and possibly die at some point in the medium-term future. If you diagnose hypothyroidism where it isn't, you'll start giving the poor bugger powerful hormones which he doesn't need and *cause* hypermetabolism.
The last word in 'diagnosis by symptoms' was the absolutely excellent paper:
Statistical Methods Applied To The Diagnosis Of Hypothyroidism by W. Z. Billewicz et al.
Connoisseurs will note the clever and careful application of 'machine learning' techniques, before there were machines to learn!
One important thing to note is that this is a way of separating hypothyroid cases from other cases of tiredness at the point where people have been referred by their GP to a specialist at a hospital on suspicion of hypothyroidism. That changes the statistics remarkably. This is *not* a way of diagnosing hypothyroidism in the general population. But if someone's been to their GP (general practitioner, the doctor that a British person likely makes first contact with) and their GP has suspected their thryoid function might be inadequate, this test should probably still work.
For instance, they consider Physical Tiredness, Mental Lethargy, Slow Cerebration, Dry Hair, and Muscle Pain, the classic symptoms of hypothyroidism, present in most cases, to be indications *against* the disease.
That's because if you didn't have these things, you likely wouldn't have got that far. So in the population they're seeing (of people whose doctor suspects they might be hypothyroid), they're not of great value either way, but their presence is likely the reason why the person's GP has referred them even though they've really got iron-deficiency anaemia or one of the other causes of fatigue.
In their population, the strongest indicators are 'Ankle Jerk' and 'Slow Movements', subtle hypothyroid symptoms which aren't likely to be present in people who are fatigued for other reasons.
But this absolutely isn't a test you should use for population screening! In the general population, the classic symptoms are strong indicators of hypothyroidism.
Probability Theory is weird, huh?
Luckily, there were lab tests for hypothyroidism too, but they were expensive, complicated, annoying and difficult to interpret. Billewicz et al used them to calibrate their test, and recommend them for the difficult cases where their test doesn't give a clear answer.
And of course, the final test is to give them thyroid treatment and see whether they get better. If you're not sure, go slow, watch very carefully and look for hyper symptoms.
Overconfidence is definitely the way to go. If you don't diagnose it and it is, that's catastrophe. If it isn't, but you diagnose it anyway, then as long as you're paying attention the hyper symptoms are easy enough to spot, and you can pull back with little harm done.
A Better Way
It should be obvious from the above that the diagnosis of hypothyroidism by symptoms is absolutely fraught with complexity, and very easy to get wrong, and if you get it wrong the bad way, it's a disaster. Doctors were absolutely screaming for a decisive way to test for hypothyroidism.
Unfortunately, testing directly for the levels of thyroid hormones is very difficult, and the tests of the 1960s weren't accurate enough to be used for diagnosis.
The answer came from an understanding of how the thyroid regulatory system works, and the development of an accurate blood test for a crucial signalling hormone.
Three structures control the level of thyroid hormones in the blood.
The thyroid gland produces the hormones and secretes them into the blood.
Its activity is controlled by the hormone thyrotropin, or Thyroid Signalling Hormone (TSH). Lots of TSH works the thyroid hard. In the absence of TSH the thyroid relaxes but doesn't switch off entirely. However the basal level of thyroid activity in the absence of TSH is far too low.
TSH is controlled by the pituitary gland, a tiny structure attached to the brain.
The pituitary itself is controlled, via Thyroid Releasing Hormone (TRH), by the hypothalamus, which is part of the brain.
This was thought to be a classic example of a feedback control system.
It turns out that the level of thyrotropin TSH in the blood is exquisitely sensitive to the levels of thyroid hormones in the blood.
Administer thyroid hormone to a patient and their TSH level will rapidly adjust downwards by an easily detectable amount.
In hypothyroidism, where the thyroid has failed, the body will be desperately trying to produce more thyroid hormones, and the TSH level will be extremely high.
In Graves' Disease, this theory says, where the thyroid has grown too large, and the metabolism is running damagingly fast, the body will be, like a central bank trying to stimulate growth in a deflationary economy by reducing interest rates, 'pushing on a piece of string'. TSH will be undetectable.
The original TSH test was developed in 1965, by the startlingly clever method of radio-immuno-assay.
[For reasons that aren't clear to me, rather than being expressed in grams/litre, or mols/litre, the TSH test is expressed in 'international units/liter'. But I don't think that that's important]
A small number of people in whom there was no suspicion of thyroid disease were assessed, and the 'normal range' of TSH was calculated.
Again, 'endocrinology history' resources are not easy to find, but the first test was not terribly sensitive, and I think originally hyperthyroidism was thought to result in a complete absence of TSH, and that the highest value considered normal was about 4 (milli-international-units/liter).
This apparently pretty much solved the problem of diagnosing thyroid disorders.
It's no longer necessary to diagnose hypo- and hyper-thyroidism by symptoms. It was error prone anyway, and the question is easily decided by a cheap and simple test.
Natural Desiccated Thyroid is one with Nineveh and Tyre.
No doctor trained since the 1980s knows much about hypothyroid symptoms.
Medical textbooks mention them only in passing, as an unweighted list of classic symptoms. You couldn't use that for diagnosis of this famously difficult disease.
If you suspect hypothyroidism, you order a TSH test. If the value of TSH is very low, that's hyperthyroidism. If the value is very high then that's hypothyroidism. Otherwise you're 'euthyroid' (greek again, good-thyroid), and your symptoms are caused by some other problem.
The treatment for hyperthyroidism is to damage the thyroid gland. There are various ways. This often results in hypothyroidism. *For reasons that are not terribly well understood*.
The treatment for hypothyroidism is to give the patient sufficient thyroxine (T4) to cause TSH levels to come back into their normal range.
The conditions hyperthyroidism and hypothyroidism are now *defined* by TSH levels.
Hypothyroidism, in particular, a fairly common disease, is considered to be such a solved problem that it's usually treated by the GP, without involving any kind of specialist.
It was found that the traditional amount of thyroxine (T4) administered to cure hypothyroid patients, was in fact too high. The amount of T4 that had always been used to replace the hormones that had once been produced by a thyroid gland now dead, destroyed, or surgically removed appeared now to be too much. That amount causes suppression of TSH to below its normal range. The brain, theory says, is asking for the level to be reduced.
The amount of T4 administered in such cases (there are many) has been reduced by a factor of around two, to the level where it produces 'normal' TSH levels in the blood. Treatment is now titrated to produce the normal levels of TSH.
TSH tests have improved enormously since their introduction, and are on their third or fourth generation. The accuracy of measurement is very good indeed.
It's now possible to detect the tiny remaining levels of TSH in overtly hyperthyroid patients, so hyperthyroidism is also now defined by the TSH test.
In England, the normal range is 0.35 to 5.5. This is considered to be the definition of 'euthyroidism'. If your levels are normal, you're fine.
If you have hypothyroid symptoms but a normal TSH level, then your symptoms are caused by something else. Look for Anaemia, look for Lyme Disease. There are hundreds of other possible causes. Once you rule out all the other causes, then it's the mysterious CFS/FMS/ME, for which there is no cause and no treatment.
If your doctor is very good, very careful and very paranoid, he might order tests of the levels of T4 and T3 directly. But actually the direct T4 and T3 tests, although much more accurate than they were in the 1960s, are quite badly standardised, and there's considerable controversy about what they actually measure. Different assay techniques can produce quite different readings. They're expensive. It's fairly common, and on the face of it perfectly reasonable, for a lab to refuse to conduct the T3 and T4 tests if the TSH level is normal.
It's been discovered that quite small increases in TSH actually predict hypothyroidism. Minute changes in thyroid hormone levels, which don't produce symptoms, cause detectable changes in the TSH levels. Normal, but slightly high values of TSH, especially in combination with the presence of thyroid related antibodies (there are several types), indicate a slight risk of one day developing hypothyroidism.
There's quite a lot of controversy about what the normal range for TSH actually is. Many doctors consider that the optimal range is 1-2, and target that range when administering thyroxine. Many think that just getting the value in the normal range is good enough. None of this is properly understood, to understate the case rather dramatically.
There are new categories, 'sub-clinical hypothyroidism' and 'sub-clinical hyperthyroidism', which are defined by abnormal TSH tests in the absence of symptoms. There is considerable controversy over whether it is a good idea to treat these, in order to prevent subtle hormonal imbalances which may cause difficult-to-detect long term problems.
Everyone is a little concerned about accidentally over-treating people, (remember that hyperthyroidism is now defined by TSH<0.35).
Hyperthyroidism has long been associated with Atrial Fibrillation (a heart problem), and Osteoporosis, both very nasty things. A large population study in Denmark recently revealed that there is a greater incidence of Atrial Fibrillation in sub-clinical hyperthyroidism, and that hypothyroidism actually has a 'protective effect' against Atrial Fibrillation.
It's known that TSH has a circadian rhythm, higher in the early morning, lower at night. This makes the test rather noisy, as your TSH level can be doubled or halved depending on what time of day you have the blood drawn.
But the big problems of the 1960s and 1970s are completely solved. We are just tidying up the details.
Many hypothyroid patients complain that they suffer from 'Tired All The Time', and have some of the classic hypothyroid symptoms, even though their TSH levels have been carefully adjusted to be in the normal range.
I've no idea how many, but opinions range from 'the great majority of patients are perfectly happy' to 'around half of hypothyroid sufferers have hypothyroid symptoms even though they're being treated'.
The internet is black with people complaining about it, and there are many books and alternative medicine practitioners trying to cure them, or possibly trying to extract as much money as possible from people in desperate need of relief from an unpleasant, debilitating and inexplicable malaise.
THE PLURAL OF ANECDOTE IS DATA.
Not good data, to be sure. But if ten people mention to you in passing that the sun is shining, you are a damned fool if you think you know nothing about the weather.
It's known that TSH ranges aren't 'normally distributed' (in the sense of Gauss/the bell curve distribution) in the healthy population.
If you log-transform them, they do look a bit more normal.
The American Academy of Clinical Biochemists, in 2003, decided to settle the question once and for all. They carefully screened out anyone with even the slightest sign that there might be anything wrong with their thyroid at all, and measured their TSH very accurately.
In their report, they said (this is a direct quote):
In the future, it is likely that the upper limit of the serum TSH euthyroid reference range will be reduced to 2.5 mIU/L because >95% of rigorously screened normal euthyroid volunteers have serum TSH values between 0.4 and 2.5 mIU/L.
Many other studies disagree, and propose wider ranges for normal TSH.
But if the AACB report were taken seriously, it would lead to diagnosis of hypothyroidism in vast numbers of people who are perfectly healthy! In fact the levels of noise in the test would put people whose thyroid systems are perfectly normal in danger of being diagnosed and inappropriately treated.
For fairly obvious reasons, biochemists have been extremely, and quite properly, reluctant to take the report of their own professional body seriously. And yet it is hard to see where the AACB have gone wrong in their report.
Neurasthenia is back.
A little after the time of the introduction of the TSH test, new forms of 'Tired All The Time' were discovered.
As I said, CFS and ME are just two names for the same thing. Fibromyalgia Syndrome (FMS) is much worse, since it is CFS with constant pain, for which there is no known cause and from which there is no relief. Most drugs make it worse.
But if you combine the three things (CFS/ME/FMS), then you get a single disease, which has a large number of very non-specific symptoms.
These symptoms are the classic symptoms of 'hypometabolism'. Any doctor who has a patient who has CFS/ME/FMS and hasn't tested their thyroid function is *de facto* incompetent. I think the vast majority of medical people would agree with this statement.
And yet, when you test the TSH levels in CFS/ME/FMS sufferers, they are perfectly normal.
All three/two/one are appalling, crippling, terrible syndromes which ruin people's lives. They are fairly common. You almost certainly know one or two sufferers. The suffering is made worse by the fact that most people believe that they're psychosomatic, which is a polite word for 'imaginary'.
And the people suffering are mainly middle-aged women. Middle-aged women are easy to ignore. Especially stupid middle-aged women who are worried about being overweight and obviously faking their symptoms in order to get drugs which are popularly believed to induce weight loss. It's clearly their hormones. Or they're trying to scrounge up welfare benefits. Or they're trying to claim insurance. Even though there's nothing wrong with them and you've checked so carefully for everything that it could possibly be.
But it's not all middle aged women. These diseases affect men, and the young. Sometimes they affect little children. Exhaustion, stupidity, constant pain. Endless other problems as your body rots away. Lifelong. No remission and no cure.
And I have Doubts of my Own
And I can't believe that careful, numerate Billewicz and his co-authors would have made this mistake, but I can't find where the doctors of the 1970s checked for the sensitivity of the TSH test.
Specificity, yes. They tested a lot of people who hadn't got any sign of hypothyroidism for TSH levels. If you're well, then your TSH level will be in a narrow range, which may be 0-6, or it may be 1-2. Opinions are weirdly divided on this point in a hard to explain way.
But Sensitivity? Where's the bit where they checked for the other arm of the conditional?
The bit where they show that no-one who's suffering from hypometabolism, and who gets well when you give them Desiccated Thyroid, had, on first contact, TSH levels outside the normal range.
If you're trying to prove A <=> B, you can't just prove A => B and call it a day. You couldn't get that past an A-level maths student. And certainly anyone with a science degree wouldn't make that error. Surely? I mean you shouldn't be able to get that past anyone who can reason their way out of a paper bag.
I'm going to say this a third time, because I think it's important and maybe it's not obvious to everyone.
If you're trying to prove that two things are the same thing, then proving that the first one is always the second one is not good enough.
IF YOU KNOW THAT THE KING OF FRANCE IS ALWAYS FRENCH, YOU DO *NOT* KNOW THAT ANYONE WHO IS FRENCH IS KING OF FRANCE.
It's possible, of course, that I've missed this bit. As I say, 'History of Endocrinology' is not one of those popular, fashionable subjects that you can easily find out about.
I wonder if they just assumed that the thyroid system was a thermostat. The analogy is still common today.
But it doesn't look like a thermostat to me. The thyroid system with its vast numbers of hormones and transforming enzymes is insanely, incomprehensibly complicated. And very poorly understood. And evolutionarily ancient. It looks as though originally it was the system that coordinated metamorphosis. Or maybe it signalled when resources were high enough to undergo metamorphosis. But whatever it did originally in our most ancient ancestors, it looks as though the blind watchmaker has layered hack after hack after hack on top of it on the way to us.
Only the thyroid originally, controlling major changes in body plan in tiny creatures that metamorphose.
Of course, humans metamorphose too, but it's all in the womb, and who measures thyroid levels in the unborn when they still look like tiny fish?
And of course, humans undergo very rapid growth and change after we are born. Especially in the brain. Baby horses can walk seconds after they're born. Baby humans take months to learn to crawl. I wonder if that's got anything to do with cretinism.
And I'm told that baby humans have very high hormone levels. I wonder why they need to be so hot? If it's a thermostat, I mean.
But then on top of the thyroid, the pituitary. I wonder what that adds to the system? If the thyroid's just a thermostat, or just a device for keeping T4 levels constant, why can't it just do the sensing itself?
What evolutionary process created the pituitary control over the thyroid? Is that the thermostat bit?
And then the hypothalamus, controlling the pituitary. Why? Why would the brain need to set the temperature when the ideal temperature of metabolic reactions is always 37C in every animal? That's the temperature everything's designed for. Why would you dial it up or down, to a place where the chemical reactions that you are don't work properly?
I can think of reasons why. Perhaps you're hibernating. Many of our ancestors must have hibernated. Maybe it's a good idea to slow the metabolism sometimes. Perhaps to conserve your fat supplies. Your stored food.
Perhaps it's a good idea to slow the metabolism in times of famine?
Perhaps the whole calories in/calories out thing is wrong, and people whose energy expenditure goes over their calorie intake have slow metabolisms, slowly sacrificing every bodily function including immune defence in order to avoid starvation.
I wonder at the willpower that could keep an animal sane in that state. While its body does everything it can to keep its precious fat reserves high so that it can get through the famine.
And then I remember about Anorexia Nervosa, where young women who want to lose weight starve themselves to the point where they no longer feel hungry at all. Another mysterious psychological disease that's just put down to crazy females. We really need some female doctors.
And I remember about Seth Robert's Shangri-La Diet, that I tried, to see if it worked, some years ago, just because it was so weird, where by eating strange things, like tasteless oil and raw sugar, you can make your appetite disappear, and lose weight. It seemed to work pretty well, to my surprise. Seth came up with it while thinking about rats. And apparently it works on rats too. I wonder why it hasn't caught on.
It seems, my female friends tell me, that a lot of diets work well for a bit, but then after a few weeks the effect just stops. If we think of a particular diet as a meme, this would seem to be its infectious period, where the host enthusiastically spreads the idea.
And I wonder about the role of the thyronine de-iodinating enzymes, and the whole fantastically complicated process of stripping the iodines and the amino acid bits from thyroxine in various patterns that no-one understands, and what could be going on there if the thyroid system were just a simple thermostat.
And I wonder about reports I am reading where elite athletes are finding themselves suffering from hypothyroidism in numbers far too large to be credible, if it wasn't, say, a physical response to calorie intake less than calorie output.
I've been looking ever so hard to find out why the TSH test, or any of the various available thyroid blood tests are a good way to assess the function of this fantastically complicated and very poorly understood system.
But every time I look, I just come up with more reasons to believe that they don't tell you very much at all.
Can anyone convince me that the converse arm has been carefully checked?
That everyone who's suffering from hypometabolism, and who gets well when you give them Desiccated Thyroid, has, before you fix them, TSH levels outside the normal range.
In other words, that we haven't just thrown, though carelessness, a long standing, perfectly safe, well tested treatment, for a horrible disabling disease that often causes excruciating pain, that the Victorians knew how to cure, and that the people of the 1950s and 60s routinely cured, away.
Summary/TL;DR: this piece offers Fermi Estimates of the value of those in EA, focusing on the distinctions between typical EA members and dedicated members (defined below). These estimates suggest that, compared to the current movement baseline, we should prioritize increasing the number of “typical” EA members and getting more non-EA people to behave like typical EA members, rather than getting typical EAs to become dedicated ones.
[Acknowledgments: Thanks to Tom Ash, Jon Behar, Ryan Carey, Denis Drescher, Michael Dickens, Stefan Schubert, Claire Zabel, Owen Cotton-Barratt, Ozzie Gooen, Linchuan Zheng, Chris Watkins, Julia Wise, Kyle Bogosian, Max Chapnick, Kaj Sotaja, Taryn East, Kathy Forth, Scott Weathers, Hunter Glenn, Alfredo Parra, William Kiely, Jay Quigley, and others who prefer to remain anonymous for looking at various draft versions of this post. Thanks to their feedback, the post underwent heavy revisions. Any remaining oversights, as well as all opinions expressed, are my responsibility.]
This article is a follow-up to "Celebrating All Who Are In Effective Altruism"
The lead article on everydayfeminism.com on March 25:
The scenario is always the same: I say we should abolish prisons, police, and the American settler state— someone tells me I’m irrational. I say we need decolonization of the land — someone tells me I’m not being realistic.... When those who are the loudest, the most disruptive — the ones who want to destroy America and all of the oppression it has brought into the world — are being silenced even by others in social justice groups, that is unacceptable.
(The link from "decolonization" is to "Decolonization is not a metaphor", to make it clear s/he means actually giving the land back to the Native Americans.)
I regularly see people who describe how social justice activists act accused of setting up a straw man. This article show that the bias of some SJWs against reason is impossible to strawman. The author argues at length that rationality is bad, and that justice arguments shouldn't be rational or be defended rationally. Ze is, or was, confused about what "rationality" means, but clearly now means it to include reason-based argumentation.
This isn't just some wacko's blog; it was chosen as the headline article for the website. I had to click around to a few other articles to make sure it wasn't a parody site.
But it isn't just a sign of how irrational the social justice movement is—it has clues to how it got that way.
Spirituality and rationality seem completely opposed. But are they really?
To get at this question, let's start with a little thought experiment. Consider the following two questions:
1. If you were given a choice between reading a physical book (or an e-book) or listening to an audiobook, which would you prefer?
2. If you were given a choice between listening to music, or looking at the grooves of a phonograph record through a microscope, which would you prefer?
But I am more interested in the answer to a third question:
3. For which of the first two questions do you have a stronger preference between the two options?
Most people will have a stronger preference in the second case than the first. But why? Both situations are in some sense the same: there is information being fed into your brain, in one case through your ears and in the other through your eyes. So why should people's preference for ears be so much stronger in the case of music than books?
There is something in the essence of music that is lost in the translation between an audio and a visual rendering. The same loss happens for words too, but to a much lesser extent. Subtle shades of emphasis and tone of voice can convey essential information in spoken language. This is one of the reasons that email is so notorious for amplifying misunderstandings. But the loss in much greater in the case of music.
The same is true for other senses. Color is one example. A blind person can abstractly understand what light is, and that color is a byproduct of the wavelength of light, and that light is a form of electromagnetic radiation... yet there is no way for a blind person to experience subjectively the difference between red and blue and green. But just because some people can't see colors doesn't mean that colors aren't real.
The same is true for spiritual experiences.
Now, before I expand that thought, I want to give you my bona fides. I am a committed rationalist, and an atheist (though I don't like to self-identify as an atheist because I'd rather focus on what I *do* believe in rather than what I don't). So I am not trying to convince you that God exists. What I want to say is rather that certain kinds of spiritual experiences *might* be more than mere fantasies made up out of whole cloth. If we ignore this possibility we risk shutting ourselves off from a vital part of the human experience.
I grew up in the deep south (Kentucky and Tennessee) in a secular Jewish family. When I was 12 my parents sent me to a Christian summer camp (there were no other kinds in Kentucky back in those days). After a week of being relentlessly proselytized (read: teased and ostracized), I decided I was tired of being the camp punching bag and so I relented and gave my heart to Jesus. I prayed, confessed my sins, and just like that I was a member of the club.
I experienced a euphoria that I cannot render into words, in exactly the same way that one cannot render into words the subjective experience of listening to music or seeing colors or eating chocolate or having sex. If you have not experienced these things for yourself, no amount of description can fill the gap. Of course, you can come to an *intellectual* understanding that "feeling the presence of the holy spirit" has nothing to do with any holy spirit. You can intellectually grasp that it is an internal mental process resulting from (probably) some kind of neurotransmitter released in response to social and internal mental stimulus. But that won't allow you to understand *what it is like* any more than understanding physics will let you understand what colors look like or what music sounds like.
Happily, there are ways to stimulate the subjective experience that I'm describing other than accepting Jesus as your Lord and Savior. Meditation, for example, can produce similar results. It can be a very powerful experience. It can even become addictive, almost like a drug.
I am not necessarily advocating that you go try to get yourself a hit of religious euphoria (though I wouldn’t discourage you either -- the experience can give you some interesting and useful perspective on life). Instead, I simply want to convince you to entertain the possibility that people might profess to believe in God for reasons other than indoctrination or stupidity. Religious texts and rituals might be attempts to share real subjective experiences that, in the absence of a detailed modern understanding of neuroscience, can appear to originate from mysterious, subtle external sources.
The reason I want to convince you to entertain this notion is that an awful lot of energy gets wasted by arguing against religious beliefs on logical grounds, pointing out contradictions in the Bible and whatnot. Such arguments tend to be ineffective, which can be very frustrating for those who advance them. The antidote for this frustration is to realize that spirituality is not about logic. It's about subjective experiences that not everyone is privy to. Logic is about looking at the grooves. Spirituality is about hearing the music.
The good news is that adopting science and reason doesn’t mean you have to give up on spirituality any more than you have to give up on music. There are myriad paths to spiritual experience, to a sense of awe and wonder at the grand tapestry of creation, to the essential existential mysteries of life and consciousness, to what religious people call “God.” Walking in the woods. Seeing the moons of Jupiter through a telescope. Gathering with friends to listen to music, or to sing, or simply to share the experience of being alive. Meditation. Any of these can be spiritual experiences if you allow them to be. In this sense, God is everywhere.
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