Scott Alexander and others on mental illness

Here is Scott’s response to Bryan Caplan’s response to Scott’s critique of Bryan’s earlier Szaszian paper on mental illness.  I can’t bring myself to do any serious recap, so I hope you care (or do I hope you don’t care?), in any case Scott serves up the links:

In 2006, Bryan Caplan wrote a critique of psychiatry. In 2015, I responded. Now it’s 2020, and Bryan has a counterargument.

Bryan rejects the concept of mental illness, believing that such individuals can be described using concepts from rational choice theory, most of all preferences and meta-preferences:

…this article argues that most mental illnesses are best modeled as extreme preferences, not constraining diseases.

Most lately, here is a snippet from Scott’s latest post:

Or what about respiratory tract infections that cause coughing? My impression is that, put a gun to my head, and I could keep myself from coughing, even when I really really felt like it. Coughing is a preference, not a constraint, and Bryan, to be consistent, would have to think of respiratory infections as just a preference for coughing…

Bryan’s preference vs. constraint model doesn’t just invalidate mental illness. It invalidates many (maybe most) physical illnesses! Even the ones it doesn’t invalidate may only get saved by some triviality we don’t care about – like how maybe you can lift less weight when you have the flu – and not by the symptoms that actually bother us.

I am fully on Scott’s side here, but I think he is being too literal in responding to Bryan’s arguments, taking on too much of Bryan’s turf.

The biggest problem with Bryan’s argument is this: let’s say you could redescribe say schizophrenia in terms of an unusual preference and other concepts from rational choice theory.  It would not follow that is all schizophrenia is.  For instance, a quick perusal of the literature shows that schizophrenic individuals may suffer from local processing deficits (moving too rapidly and too indiscriminately to global processing), working memory defects, inability to maintain attention, disorganized behavior, hypo- and hyper-excitability, excessive speculative ideation, excess receptivity to information from the right hemisphere of the brain, and delusions.

Of course that account is contested at some margins, as is typically the case in a research literature, but you get the point.  Schizophrenia could be some combination of an extreme preference, whatever else Bryan wishes to toss in, and some version of that list from the paragraph directly above.  Bryan works very hard to “rule in” his redescription of various mental illnesses, but he doesn’t and indeed cannot do much to rule out what are in fact the relevant cognitive or sometimes personality traits of the phenomenon in question.

And if you ask “Ah, what about the ‘normal’ people who claim that God is talking to them?”, well most of them have only a limited number of the features on that above list.  Some of course may in fact be schizophrenic or fall into the broader schizotypic category.  Those supposed reductios about the supposedly wacky religious people just don’t much dent the category of schizophrenia.  There might even be a correlation in the data between religious behavior and schizotypy — why not? — but the two are by no means cognitively identical.

Ask Bryan a simple question: do the individuals diagnosed as schizophrenia in fact have some combination of those traits listed above to an unusual degree?  If he answers “yes,” he has in fact conceded the argument.  If he answers “no,” he needs to counter a huge and established literature with empirics of his own, which of course he has not done.  The broader point is you cannot usually vanquish empirical categories with philosophical and methodological arguments alone.

I do partially side with Bryan only in one regard: I don’t find the term “mental illness” very useful, and very often it is misleading, or even dangerous, or used to restrict the liberties of individuals unjustly.  I very much prefer a more disaggregated approach, citing more exact information about a person’s condition, rather than applying a very general label in a manner that could end up being irresponsible.  It seems to me that a more disaggregated description is almost always possible, maybe always possible.

But you shouldn’t take that brand of skepticism as endorsing the kind of mono-conceptual straitjacket Bryan wishes to impose on this whole problem.


I wonder if Bryan Caplan's belief in free will also influenced his rather idiosyncratic views on mental illness.

It is obvious he has never actually dealt with someone who is mentally ill.

Bryan Caplan is crazy, which is why his ideas are so interesting.

Diversity is our strength.

One can wonder how Caplan explains the effect of lithium, or how it can be routinely used to reliably and empirically distinguish between those with schizophrenia and those experiencing a manic episode after roughly two weeks in a setting where it is consistently administered.

On this blog it's generally considered cheating to introduce sciencey evidence like that.

He has argued that the mere fact that a chemical has psychological effects doesn't mean one was "ill" or "deficient" in it. But currently both bipolar people with manic episodes as well as schizophrenics are both considered mentally ill.

I recently learned that (involuntary) eye movement (anyone who argues that is a "cholce" isn't worth debating) has a 98% correlation with (adult) schizophrenia. Which is astounding. I also think that "choice" is a word that needs to be used in a carefully constructed context to have (rational) utility. OTOH. The population frequencies of mental illnesses are culturally dependent. So, while he is possibly correct in his belief that some symptomatic behavior is choice, some is learned and a good part is physiologic. In a way this becomes the nature vs nurture debate all over again. News Flash! The debate was settled decades ago: it is both, they are constantly interacting and useful separation is often impossible.

Let us be very careful about what rational choice theory implies and what it doesn't. The usual shorthand - people respond to incentives - is not complete. Rather, people change their behavior in response to a change in incentive is what is meant.

In that sense, it has been found that individuals [not all individuals] who have been institutionalized upon the advice of psychiatrists indeed do respond to changes in incentives. If they have to give up more chewing gum to get more oranges, they choose less chewing gum and more oranges.

But that is all.

For all my sympathy with Caplan's position, rational choice theory helps us very little in discriminating between those who are sane and those who are not. Other criteria are necessary to determine this distinction, if one wants to make the distinction.

On this one Caplan is crackers. He obviously doesn't have any experience w/ people who have these conditions.

I read the arguments and Caplan is trying to play a psychiatrist without any knowledge of medicine or neuroscience. Hubris at its highest


And Dunning-Krueger too.

Smart people are often the most unselfconsciously biased - they are so intelligent their narratives are often the most bullet resistant. They are also accustomed to being right.

No, he's not. He's calling into question the validity of psychiatry. And that's a reasonable thing to do. The trouble is, it's doubtful that Caplan himself is talented enough as a general thinker to make the case he wishes to make, and Caplan is himself impaired in odd ways. Szasz as a psychiatrist had an informed opinion about it, but in critiquing psychiatry, he was writing outside its core assumptions. For a more vernacular and less profound critique, see Fuller Torrey.

In effect, Caplan is the guy who has been unable to identify any suckers at the poker table, and so he is declaring that suckers don't really exist.

An ironic statement, given Caplan's track-record of taking money from the suckers who bet against him.

It is highly unlikely that Caplan has never had significant interactions with people with diagnosible mental illness. I agree with your first contention: that on this issue he IS crackers (i.e. suffering from a mental failure). As to the other, it is far more likely that he has chosen to ignore the evidence contradicting his egregiously risible position.

If I had to guess, I'd wager Bryan Caplan has never had what the rest of us would consider a significant interaction with another person of any description. He's married of course. Women often like pets.

Or he is a Scientologist.

Or a Christian Scientist. I guarantee you'll understand the power of positive thinking if I put a gun to your head. Think positively!

Maybe Caplan is playing a strategic game of attempting to move the equilibrium of the discussion. Maybe he (wrongly or rightly, you decide) sees discussions of mental illness as a term increasingly tossed-around too loosely as a get-out-of-jail-free card for various unideal behaviors, and he just wants to pull the discussion into more rational territory, modeling it as a set of behavioral preferences that others are free to dislike and disagree with without being “ableist” or “bigots”.

Or alternatively, a get thrown into jail card. As happened to this man currently running for Congress. This is from the Post a couple of days ago - The bowling party occurred about a week before police were called to Trump’s Doral resort in Miami-Dade County for a “male in distress fearing for his life,” according to a police report from the incident.

Hyde told officers that he had been “set up and that a hit man was out to get him,” officers wrote. Hyde “spoke about emails he sent that may have placed his life in jeopardy” and said he believed that painters and landscape workers were trying to harm him and that the Secret Service was watching him.

Doral police classified the May 16 episode as a “Baker/Marchman Act” incident, referring to the Florida laws that allow a person to be involuntarily detained and treated for mental illness or substance abuse.

In a now-deleted social media post at the end of May, Hyde described being “Baker Acted” for nine days. “I passed all medicals, physicals, psych exams and diagnosis with flying colors . . . So in all honesty, eff you and your intelligence agencies, whatever or whoever was or is effing with me.”

Cannot say anything about the private resort employees, but the Secret Service watches everyone in a place where the president is present or regularly expected to be present.

If schizophrenia is just a case of extreme preferences, then why do anti-psychotics work? Do they change preferences? Economists generally take preferences as given. The whole concept becomes pretty useless if preferences are so malleable that a single injection of Haldol can, within a couple of days, change them completely. I have witnessed up close and personal the difference an antipsychotic can make in the thinking of someone in a full-blown schizophrenic episode.
Other things about schizophrenia don't fit Caplan's model either. Auditory hallucinations, for example. The schizophrenic I know personally heard a voice talking to her as clearly as you would hear me if I were talking to you across a coffee table in a quiet living room. She had been instructed in Christianity as a child, but never took it seriously until she started hearing these voices. Look around, nobody there with you, it must be God or an angel talking to you.
Another was the fascination with colors. More than once I retrieved her from a neighbor's yard where she had been standing for hours just utterly fascinated by the colors of the flowers. They had some deep and important meaning, she was sure. Preferences? Really?
Caplan should read someone like E. Fuller Torrey on what the disorder really is.


A decade ago I lost a brother to schizophrenia that we're pretty sure caused him to commit suicide after he stopped taking his medication for the 100th+ time in a row (schizophrenics are notorious for stopping meds). The drugs definitely worked and definitely changed preferences which is the surest evidence he's way off. Brain and brain chemical abnormalities and imbalances are real.

+1 so sorry for your loss

Caplan actually has discussed the effectiveness of medications for medical illnesses in his argument, although not everyone would find his argument convincing.

I am curious: if schizophrenia drugs are effective at changing the "preferences" of the schizophrenics who take them, why are these medicated schizophrenics still "notorious" for going off their meds? Are the side effects very unpleasant?

We lost a mentally ill friend to suicide. We were astonished to find that our first instinct on hearing of his death was rage. "How could you, David? Bloody Hell, how could you?" Later it was grief: "Oh, you poor bastard, David. You poor, poor, troubled soul."

The response of the sane to the mad may itself be less than rational.

Later we found out that the immediate cause was some sort of difficulty he had had in getting his medication. Oh the pity!

I am sorry for your loss.

I lost someone to depression and suicide and another to self-education.

That your friend couldn't get his meds makes it even more tragic. Horrible.

The reason this argument persists is that neither party has more than a superficial understanding of the topics they are discussing.

Pirsig would disagree, but he had more insight into this discussion than most considering his experiences and beliefs one can see expressed in his writing.

Basically, he would say that mental illness exists, and that those in charge of caring for the mentally ill are the ones most likely to actively resist any attempt to discuss how it is defined by society.

Pretty sure Scott Alexander has a day job as a psychiatrist, so I'm inclined to believe he has some idea what he's talking about on this subject, and even though Caplan makes some interesting points, it's clear that he has much less expertise and shouldn't be so confident.

He does indeed. Recently completed a residency and now practices in the San Francisco Bay Area.

I think LBM is arguing that psychiatrists have no more than a superficial understanding of mental illness. I'm not sure Scott would disagree.

In this whole line of argument Caplan is putting some very bizarre preferences on display. Or is he crazy? You decide.

Hehe. +1

Does the stable genius suffer from a mental illness or is he just an ignoramus? In either case, what of the millions of his followers: do they suffer from a mental illness or are they just ignoramuses? And what of the religious: do they suffer from a mental illness or are they just seeking an explanation for all those who suffer including, yes, those with a mental illness? I often watch Michael Shermer's podcasts. Last night I watched his interview of Richard Dawkins. It brings to mind Thomas Jefferson's expression: when two or more atheists gather, humor is afar. Cowen, bless his little heart, finds great value in being different. Cowen is not alone. Here's Steve Jobs:

“Here’s to the crazy ones, the misfits, the rebels, the troublemakers, the round pegs in the square holes… the ones who see things differently — they’re not fond of rules… You can quote them, disagree with them, glorify or vilify them, but the only thing you can’t do is ignore them because they change things… they push the human race forward, and while some may see them as the crazy ones, we see genius, because the ones who are crazy enough to think that they can change the world, are the ones who do.”

See now, Ray? This is the right thread for you to talk about Trump.

I believe most serious mental illness is real, I've lived with near relatives who have suffered it. However that said I think that there is a cohort of depressives who are really depressed but wallow in their misery and in a perverse sort of way enjoy the misery. Strange but my experience leads me to that conclusion.

"there is a cohort of depressives who are really depressed but wallow in their misery"

IME personality definitely impacts how different people cope with similar problems. It is true that some bipolar people stay on their medications and make heroic and successful efforts to manage their problems, while others just fall off a cliff.

One of the big issues in managing serious mental illness is the side-effects created by the drugs, which no doubt some people find much more difficult to cope with than others, just as is the case with the illness itself

This may provoke some thinking about the mind and what we don't know. And for many, about themselves.

"For most people the use of visual imagery is pervasive in daily life, but for a small group of people the experience of visual imagery is entirely unknown. Research based on subjective phenomenology indicates that otherwise healthy people can completely lack the experience of visual
Imagery, a condition now referred to as aphantasia."
"The blind mind: No sensory visual imagery in aphantasia."
Keogh R1, Pearson J2.

Other medical literature can be found on
Note links to working memory

"Aphantasia and severely deficient autobiographical memory: Scientific and personal perspectives."

PubMed search page results include brain imaging studies.

I think, his insane and uncalled for bigotry apart, Mr. Alexander has a strong point. It is unproductive to treat mental illness as just another set of preferences.

I'm afraid I'm suffering from Caplan insomnia tonight. I'm having a really hard time changing my preference to sleep from lying in awake in bed for hours.

Caplan is being an idiot.

"Most mental diseases amount to nothing more than to nothing more than unusual preferences. They do not affect what a person can do, only what they want to do,"

And this is obviously bunk. Take a simple, common symptom of mental illness: insomnia. I have had PTSD patients who have been unable to sleep for days. They report minimal sleep, intrusive nightmares, and generally feel like crap (i.e. it has gotten so bad they came to the ED for treatment). On questioning they acknowledge doing all the things one might try to sleep soundly: going to bed, limiting screen/light exposure, black out curtains, white noise, caffeine avoidance, sleep aids, "overdosing" on sleep aids, taking a night cap, having sex, getting drunk, etc. It seems awfully stupid to say these people have a "preference" for insomnia when that contradicts both their stated preferences and the actions they have taken at some cost. I mean seriously, if they just want to remain awake and ruminate (or whatever) the easiest option is just to not go to bed.

Here are people with a psychiatric disease that cannot do something even though they go to great effort to achieve it. Shockingly, having the HPA axis dump a bunch of cortisol has the same affect on alertness regardless of the triggering stimuli.

And PTSD is not alone in this. Depression can often cause a patient to be unable to sleep in spite of taking many and obvious actions to sleep. Scizophrenia, bipolar, and host of other psychiatric illnesses can all result in an inability of patients to do something that is both vital for health and well being, but also something they want to do.

Funnily enough, treating these disorders (with things like Prazosin, Lithium, or SSRIs respectively) most often changes their ability to sleep.

Or take another symptom: impotence. Patients may desire to have sexual relations with their spouse. They may seek out visual stimuli, have partner or self tactile stimulation, seek out prostitutes, or try any number of sexual aids to achieve an erection. Yet even with PDE5 inhibitors, these patients can still fail to achieve erections; yet when they are treated for a psychiatric illness they sometimes reacquire potency without direct treatment for impotence.

Or take Caplan's ur-illness of substance use disorder. Individuals with it perform worse on the Iowa Gambling Task. They do worse in spite of financial incentives (that can easily be converted to their preferred drug) to do well. In spite of efforts to improve, they typically do worse than matched controls and they do worse whether actively using or after detoxing. In fact, substance use disorder patients will often have worse performance at the IGT and recognize it but be unable to stop to picking the bad decks nonetheless.

Frankly, Mr. Caplan's approach is far more infantilizing and paternalizing than modern psychiatry. Taking him seriously means that we must ignore patients' stated preferences as though they are liars or idiots. Taking Mr. Caplan seriously, means that we must further ignore the many, expensive things patients try to overcome the very things he believes are their "true" preferences. I have known more than one patient who has killed themselves after some well meaning busybody has taken Mr. Caplan's approach.

I think Caplan would treat insomnia and impotence as real diseases and not preferences under the “gun to the head” test. If you held a gun to someone’s head and said you’d shoot them unless they went to sleep or had an erection, they could very well fail (in fact they’d probably be more likely to fail).

But how can a non-disease produce symptoms that Caplan might agree are diseases in their own right? This strikes me as fatal to Caplan's argument unless he wants to try to claim that these symptoms are not caused by what his critics call mental illness.

Why? Insomnia uses the same sort of DSM classification system as the diseases he disputes.

Further, I have had success treating these "fake" diseases with things like Lithium. Lithium is a terrible sleep aid, but somehow works really well for my bipolar patients. And I have certainly had many patients who failed primary treatment for insomnia but responded to atypical antipsychotic or an alpha blocker which just so happen to be indicated for their primary disorder.

I think you've overstated your case.

Someone who had schizophrenia lived in my house for over a decade. Bryan is speaking from ignorance, when analyzing using only the tools he is familiar with from the field of economics. Many forms of mental illness do not manifest themselves very severely, so whether those are true illnesses might be debated, but schizophrenia is not one of them.

An inability to think as one used to, which is mostly correctable by medication (not universally, though), is not just making unusual choices. It is caused by a malfunctioning brain. Convincing someone not to kill their mother because someone believes she is the bride of Satan wasn't possible for me. I just managed to calm this person down long enough for the police and EMTs to arrive. Medication over the following year worked miracles...until the inevitable periods where the medication is discarded and not used. Thankfully, this person has maintained enough periods of lucidity over the years since, but you can really tell when the meds are being used or not.

Bryan is not an outlier. The whole field of economics seems to be full of people hypothesizing then arguing then playing with data to prove their point. It probably will never become a true science. After carefully paying attention for much of my 62 years, I am convinced that the people in the field, no matter how smart, are not able to harness logic and analysis well enough to ever fix economics.

The saddest part of schizophrenia are perhaps the negative symptoms. People will stare at a blank tv or the wall for hours on end and do not experience the joys and sorrows of life. This is what is left after the medications take their effect and eliminate the psychosis, and negative symptoms are impossible to treat with current medicine.

Ehhh, take 200 micrograms of lysergic acid diethylamide tonight and call back in the morning--late morning, if you please.

That Caplan nutter is the one for open borders?

He’s not mentally ill. He just has crazy preferences that would turn America into a dystopian hellhole.

I don’t think any of the Democratic Presidential candidates say they’re for open borders, but the policies they advocate amount to about the same thing.

But I hold Caplin to a substantially higher standard than the one-note Vermont Castroite, the woman who is Native American when it generates more intersectionality points, and Joe Biden.

Yeah, but there’s no chance Caplan becomes President.

1. It is becoming increasingly clear that most traits are not caused by a single gene or even a few genes. Hundreds or thousands are more like it. That means that most traits are on a continuum. Some people get enough "bad" genes that they get a diagnosis of schizophrenia. Members of their family will probably have some "unusual" behaviors. This idea is well fleshed out in Randolph Nesse's Good Reasons for Bad Feelings: Insights from the Frontier of Evolutionary Psychiatry.

2. DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, 5th edition), which insurance companies treat as a bible for billing purposes, basically says, "Everyone is weird. If that weirdness makes your life difficult, it is a mental disorder with a billing code, and you should see a professional about it. If it's not a problem, it's not a disorder."

3. Lots of substances are "psychoactive". They change the way your brain works and how you feel. "Alcohol makes me loosen up." Does that violate the idea that preferences are given? To take a reductio ad absurdum, "When I'm hungry, I'm get tired and ornery. Eating makes me happy again." If the fact that some substance changed your brain meant that there was an underlying illness, just about everyone would be sick.

I suppose I'm saying, "It's complicated."

3. Several examples have been provided in the thread of physical symptoms caused by mental illness. Involuntary eye movement, impotence and insomnia, for instance. And successfully treating the underlying mental illness seems to also cure these symptoms.

In regards to the spectrum or continuum, I can't do better than this Scott Alexander post in which he addresses the philosophical and linguistic challenge of defining "disease":

It is complicated but so is categorization in general. Define "mountain," "planet," "living being," etc. This is linguistics and philosophy 101. The challenge of coming up with a precise and comprehensive definition for each doesn't mean that these categories are not useful for understanding the world and trying to solve concrete problems.

I agree.

Some people get enough "bad" genes that they get a diagnosis of schizophrenia.

Schizophrenia is not just a compilation of "off" behaviors. It has specific symptoms such as auditory hallucinations (most commonly), delusions, and beliefs about having supernatural powers or being persecuted. You don't get a disagnosis of schizophenia by having enough "bad" genes. You have to have very specific genetic mutations or (more likely) specific developmental defects in your brain. IIRC the theory is that something goes awry during brain development that causes people to audibly "hear" their own thoughts as if they were coming from outside, though there's more to it than that - the auditory hallucinations are a symptom of the underlying brain defect, not the cause.

I think Caplan and Alexander both make some good points here, but ultimately come down more on Alexander’s side. On the one hand, Caplan’s gun to the head test makes sense to me, if you’re able to do something under extreme duress, then that means it wasn’t impossible for you to do it so on some level you didn’t do it because of a preference. However I think a lot of mental diseases would fail the “gun to the head” test, so even under that test a lot of mental diseases should be properly thought of as constraints. Like depression for example, I don’t think it would work to hold a gun to someone’s head and threaten to shoot them if they stayed depressed.

More fundamentally, I don’t think the gun to the head test really works. Let’s say the price of apples suddenly doubled and as a result, someone eats fewer apples. Sure if you held a gun to their head you could probably get them to eat the same number of apples as before. But still, people would consider the increased price of apples to be a constraint since it makes it more expensive for you to do what you want rather than a preference. Similarly in the mental world, if someone has a low IQ, sure they might be able to understand calculus if you held a gun to their head and forced them to study all day and night, but low-IQ should still be thought of as a constraint because it makes it harder for the low-IQ person to learn calculus than the high-IQ person, requiring more time and mental effort. Mental diseases like ADHD seem analogous to low-IQ for me. Sure, with enough effort, you could potentially overcome them, but they are still constraints that require you to spend effort on something others could do effortlessly.

The one type of disease where I do agree with Caplan though is the concept of addiction. Addiction does seem conceptually the same as a very strong preference, especially as people can't seem to agree on what is addictive (are video games and porn addictive?). Of course, addiction may crowd out people's other preferences by taking up time and money that they would have spent on other things, thus addicts sometimes seek treatment the way people may seek financial counseling to help them prioritize where to spend their limited resources or try Internet self-help regimes like abstaining from porn. However, when people say that addiction is not a true preference and force addicts into treatment or jail, it smacks of paternalism.

Let's say I, a normal person, have never taken an opiate in my life. I am prescribed one after surgery, something clicks, and I become an addict.

Should I really be sent to a psychologist for counseling at that point?

Maybe that's the best we have to offer, but it isn't really a psychology problem. It's a chemistry problem. And so you don't need better psychology, you need better controls on opiates, or ideally a chemical reset of some kind.

See also Native American populations with low historic exposure to alcohol.

Even addiction has constraint elements. The Iowa Gambling Task has participants choose to draw from 4 decks to receive either rewards (typically cash) or punishments (typically less cash). Over time (e.g. 100 draws) normal participants learn which decks have the best average payouts (some decks have negative expected payouts by varying the size and frequency of the payouts/penalties) and stop playing the poor outcome decks.

Patients with Alcohol use disorder are often unable to maximize their payout at this task. They clearly want the win (money, if nothing else, can be easily converted to booze) and actively try to improve their performance. But the neural circuitry which weighs risk and reward just seems to be … constrained.

You could argue that addicts don't really prefer winning money, but not is this dumb a priori, even patients desperate enough to turn to unwanted prostitution or loan sharks do poorly at IGT.

Ultimately, Caplan's thesis is pretty silly. Suppose you are addicted to cocaine. We know that movie stars (e.g. Charlie Sheen) can consume over a grand a day of cocaine. Maximizing your cocaine consumption would then best occur by doing it at times that do not interfere with work and having a steady supply of money from a highly remunerating career.

Yet I have never met anyone who has gotten a highly remunerating job after getting addicted to cocaine. I have met innumerable people who had a good paying job, did a bunch of coke, lost the good paying job, and then turned to crime to consume far less coke every day.

How on earth is this just a preference if addicts are destroying their lives and quickly ending up with less ability to indulge their preference? It is almost as though being addicted changes their ability to do things like rational risk/benefit calculations. It is almost as though having done large amounts of drugs, their brains now deficits in attention, memory, verbal processing and the like.

And I have met addicts at all points in the process. When they first start using, when they use as much as their current situation can afford, when their use starts diminishing their ability to afford their use, and when they crash and can no longer afford to use. I have asked in the middle what they expect to happen, and a sizeable number expect that they will lose their job and be able to afford fewer/inferior highs if they keep using in their current pattern. Yet these same patients have come back later homeless and consuming far less drugs because they are no longer able to afford it.

Even if we just use "ability to procure cocaine" as our metric, cocaine use disorder patients seem to be constrained over time.

I mean seriously, Caplan's logic is:
1. These people prefer to use cocaine to everything else.
2. They end up in situations where they can no longer consume as much cocaine.
3. They are not constrained so they must prefer cocaine less while be homeless than back when they had a job.

Similarly in the mental world, if someone has a low IQ, sure they might be able to understand calculus if you held a gun to their head and forced them to study all day and night

I disagree with this. Mental incapacity can not be overcome merely with a gun to the head.

I am very surprised that rayward did not go for the very obvious Trump tie-in.

As crazy as this theory seems when baldly stated, we as a nation are very busy pretending madness is in fact some kind of rational choice theory.

Hmmm, fascinating Dr. anon. But I think we should run a “second term for Trump” experiment, just to see if rayward really is mad.

If we're going to try and refute broad generalizations using discrete examples, here's a few from my own experience:

- A female colleague was feeling angry about her life. Her no doubt well-meaning boyfriend (not me), who had been diagnosed with depression and given a drug to take to alleviate it, offered to let her try his meds to see if they would help. She told me--I quote--"I was still p*ssed off at everything, but now I didn't give a sh*t anymore."

- Another friend had a son in public school who apparently was "acting out" as they say. He was "diagnosed" with some "mental illness" (probably ADHD, but I can't swear to it) and made to take meds by the school without his parents even knowing about it (let alone giving consent). Presently, the meds not having the desired effect, the school kept upping the ante. When they finally got to the point where they couldn't administer the next in line--one of the strong anti-psychotics, I forget which--they finally had to inform the parents, who were understandably horrified and refused.

- I had a serious accident when I was in school, which--long story short--led the school authorities to conclude I might be suicidal. I was involuntarily committed to a psych ward for "observation" for nearly two weeks, and they wouldn't let me out until I agreed to undergo a course of psychotherapy. That could have lasted forever until--after several months--I finally figured out I needed to regurgitate the responses the therapist wanted to hear, at which point she pronounced me cured.

Arguing the merits or demerits of whether "mental illness" is a thing or whether specific conditions warrant being so classified based on individual cases is meaningless. The acid test is whether these "diseases" can be "cured" or at the least mitigated and controlled--and by that I don't mean the kind of medical or surgical lobotomy that my woman friend experienced.

And while we're on the topic of--shall we say--weak arguments, it's true that Caplan is not a psychiatrist...but the man who first put these arguments in play, the late Thomas Szasz, most certainly was.

So feel free to dismiss Caplan all you like, the gravamen of his argument was originally propounded by a man who had all the fancy degrees (to say nothing of actual, hands-on experience) you could wish for.

On the main topic, it's simple. If brain injury can produce mental illness, then it's mad to dress up the choices of that injured brain as rational.

But as David describes, it can be hard for medicine to detect (let alone correct) less obvious, perhaps more intrinsic, problems.

Caplan has made rationality tautological. If someone gouges their eyes out (true example), then they were just pursuing their preference for being blind. If someone is incoherent, they were just pursuing their preferences for incoherence. Nothing is explained.

Preference requires rational thought, tautologically speaking, right? Perhaps based on Judeo-Christian values or Enlightenment thinking, “danger to self” is not considered rational.

Caplan's Dunning-Kruger readings are off the charts here.

+10, yes, wow, what a damned fool he is.

Agree fully!!

Ha! Seriously, this is it. +100

While these guys are arguing, genetics has passed them all by. Check out the results from large scale GWAS studies of genetics, and read Robert Plomin's stuff on "the abnormal is normal."

Executive summary:

-- Traditional mental illness taxonomy doesn't match what's going on in your brain (which we pretty much knew even from pre-GWAS heritability studies).

-- All mental illnesses, like IQ, are polygenetic, lots of small contributions from many genes.

-- ... Which means that genes for each mental illness cluster are normally distributed in all people: everyone falls somewhere on a bell curve the right tail of which are the mental patients ...

-- ... But all mental illnesses are spectra, and everyone is on the spectrum; only the right tail people are clinical.

-- We do not yet know exactly what left tail people are like: what is a far left tail schizophrenic like? In other words, what is it to be the inverse of a schizophrenic, genetically, most of those genes switched the other way?

This seems correct, but it only covers genetic origins. Chronic traumatic encephalopathy (CTE) is about brain injury. "Symptoms may include behavioral problems, mood problems, and problems with thinking."

I think there might be a fuzzy border between genetics and environment, especially when the environment includes things like drugs and football.

It's a little more complicated than that. Plomin sets out his views in Blueprint. More details in Randolph Nesse's fascinating Good Reasons for Bad Feelings: Insights from the Frontier of Evolutionary Psychiatry (both 2019).

Actually Scott Alexander had an interest take on how autism and schizophrenia seem to be opposites.

Unfortunately there is nothing rational about mental illness: rationale thought is eclipsed by disruption in consciousness and orientation. The DSM-V is a somewhat clumsy attempt to categorize mental illness by symptoms *only* for the purposes of treatment and billing, moreover coding for various databases. In this way, the taxonomy is not designed to pigeonhole someone or label them in larger society. There is a deductive process during psychiatric evaluation that offers differential diagnoses if symptoms are not “frank” or clear cut. Various “rule-out” diagnoses or working diagnoses are offered while more historical information about symptoms is acquired to “deduce” the appropriate diagnosis. Bipolar disorder can only be diagnosed if there is a manic episode. Psychiatry is very powerful, not just due to medications but also mental hygiene efforts to help restore quality of life. It relies on a confluence of medicine, psychology, sociology and philosophy. The latter, most importantly, as we discuss rational thought and existence, specially in a somewhat Cartesian context. Schizophrenia has further delineated to include “Schizoaffective” to incorporated mood symptoms that are often absent with schizophrenia. It’s all a fascinating work in progress.

"For instance, a quick perusal of the literature shows that schizophrenic individuals may suffer from local processing deficits (moving too rapidly and too indiscriminately to global processing), working memory defects, inability to maintain attention, disorganized behavior, hypo- and hyper-excitability, excessive speculative ideation, excess receptivity to information from the right hemisphere of the brain, and delusions."

If these are instances of mental "illness," then I don't see how just being very, very stupid isn't an "illness" in exactly the same respect. There isn't any reason to rule out "cognitive ability" being "treatable" one day.

Fascinating! People are still talking about Tom Szasz' points decades later! Of course, this is an economics blog, and while there are only some commenters with medical/psych experience (and others with direct personal experience and some knowledge of genetics), but there are no neuroscientists represented!

Also interesting that noone has yet mentioned Julian Jayne's ideas. Or Gregory Bateson's, let alone the ideas about mental illness that Peter Shaeffer dramatized in "Equus".

Most amazing, since this is an econ arena, no discussions of a continuum scale.

Much of Szasz' original points were, I believe, to underscore the degree to which a "diagnosis" of mental illness was less than fully "scientific", and more affected by factors of social conformity. He wrote at a time when those in the West believed (with good evidence) that Communist states were using diagnoses of mental illness to remove unwanted points of view from the political discussion. Szasz was in part concerned that this might also be happening, unacknowledged, in the West.

If Szasz' ideas are still being brought up so much later, that in itself might suggest that there is some element of validity to them, even if Mr. Caplan's arguments overstate or misrepresent important points. Perhaps taking a scalpel to these ideas, rather than a bludgeon, might be more productive...

>or even dangerous

What is it with lefties? Words are always "dangerous."

If you don't talk like a lefty, PEOPLE WILL DIE HORRIBLY.

Spoken like a true partisan! What a ridiculous idea! How could words ever be considered dangerous!

Why, that's like saying that a pen might be mightier than a sword!

What idiot person would ever believe that kind of stuff?

Watch it little man - your Argument By Cliche is going to get someone killed!!!

I am

Of two minds

About this conversation.

re discussion of Schizophrenia, if you didn't get it.

Schizophrenia is NOT Multiple-Personality Disorder. I thought that misunderstanding had been cleared up.

Bryan rejects the concept of mental illness,

Cue Mandy Rice-Davies.

The purview of the social work and mental health trade grew absurdly large during the post-war period and purveyors of the talking cure were generally effective at one object: getting paid for listening to distressed people talk. That having been said, Szasz was a provacateur who was mostly talking out of his ass. And we know from Clayton Cramer's research just why: during his residency, he assiduously and successfully avoided interactions with schizophrenics.

yes, while "avoidance" is not the best word, reducing the conversation to more concrete terms generally benefits the schizophrenic.

There is no way that Caplan, or anyone else, is stupid enough to believe this.

Just as Tyler will often post things that are laughingly false on their face, this guy will apparently say them - in both cases, just because they seem interesting and get them attention.

Sounds like a mental illness that “economists” are prone to.

It seems to me that a great many people who are depressed have a reason to be depressed: lost a job, divorce, etc. That said, it seems that depression can be self-reinforcing as if something chemical happens. Schizophrenia can be shown to result in unique brain electrical activity.

There is also, however, a role for pure choice in behavior. If someone decides the world is unfair and they are going to get what they deserve, they may adopt mean and illegal behaviors. People divorce sometimes purely because they are bored or "deserve better" or "want to find themselves"--not because the marriage isn't working. These are cognitive triggers for adverse behaviors.

I think Caplan is off-target. What we should really be criticizing is the psychiatric community's attempt to classify mental illnesses based not on medicine, but on political and financial grounds. Should condition X be in the DSM? Often the decision-making looks like this: "Well, if we add it to the DSM it will be stigmatizing for that group. That's bad. But on the other hand they can then use it to get disability or other accommodation, or to get their prescriptions covered by insurance."

Neither of those criteria are medical issues. Mental conditions get added and removed from the DSM based in politics and advocacy, not science. And the incentives for the psychiatric community all push them towards increasing medicalization of normal human variation. More treatments, more billing, more power for psychiatrists to have influence over other people's lives.

If being in the DSM meant that psychiatrists had to treat you for free, it would be a much smaller book.

About the size of The Wit and Wisdom of Elizabeth Warren.

The right question is who do the symptoms bother.

Glad to see everyone in general agreement that Caplan is basically wrong here. Some nuance to his wrongness, but still mostly off base.

Mental Illness:. Excluding very seriously mentally ill people:
The Human Organism is utilizing such a small...but Highly AVAILABLE portion of their Resources, maybe we are all , maybe, somewhat mentally ill....Of course there are Exceptions.. .. Super Liberals Social Policies, especially 9 month Abortions/killings...Now that's MENTAL ILLNESS!!

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