There has been an interesting conversation between Scott Alexander and Bryan Caplan about the nature of mental illness, essentially questioning whether our conceptions of mental health are legitimate or not. You can find this conversation at this link.
One interesting part is when Scott compares ADHD to someone with the flu, noting that they may both present with skipping work, laying in bed all day, and having low energy. On the other hand, Bryan takes some position closer to ADHD manifesting from a difference in preferences. Whether ADHD is a mental illness or comes down to a difference in preferences seems to be a semantic problem in this particular case. When we have the flu, the low energy we feel is arguably a mental illness induced by influenza, an evolved fatigue response to sickness that proved useful in ancient history. The reality is probably that the flu hijacks our preferences and causes us to want to stay in bed and skip work because this has some evolutionary advantage over working harder during sickness.
We can even disrupt this flu-induced mental illness/preference to be less effortful by using psychoactive drugs, probably even the same ones that are used for treating ADHD, stimulants. So it isn’t so much that the flu physically cripples us but instead, it may induce a kind of biological fatigue switch that could probably be modified by drugs. Similarly, the anesthetic known as PCP may be a treatment for exertion fatigue, the mental illness caused by physical exertion. This allows users to exert themselves to death and even lift cars as the old story goes.
On the topic of preferences, I’ve described how non-conformity can lead to mental health problems many times before. I’ve brought up the case of veganism and how it is a belief that really hurts in daily life. I’ve even detailed my own subjective experiences with being vegan and experiencing rising antisocial impulses due to the constant stream of microaggressions in Justified Sociopathy. Even before exploring this topic with veganism, I’ve talked about the social defeat hypothesis of schizophrenia very frequently and how stress from deviance of norms might even produce severe mental health issues and even psychosis.
It isn’t as simple as the deviance itself somehow causing symptoms. It is the loneliness, bullying, lack of support, and the inability to use social means to recover from stress. It is also the chronic pain of feeling persecuted or that your peers are enemies. If you have heard of the concept of culture shock, it could be somewhat similar. Such deviance from your local culture for long periods of time could result in something akin to late-stage culture shock. In this case, it might be that preferences cause an individual to acquire mental health problems that an individual is not fully aware of the role of these preferences.
In the case of ADHD, besides the symptoms related to genetics, the way that people develop an identity sculpted by their experiences with these symptoms creates new layers of problems that only exist because of the dynamic dance between the individual’s symptoms and their environment. As an example, our motivation is highly contingent on the belief that exertion is worth it, namely that the goal is plausible to achieve. Despite that you would love to use magic to fly, you exert no effort to achieve this because you believe it to be impossible. For those who believe they are dumb or incapable of success, many tasks begin to fall into impossibility territory. The more that their lives fall apart, the more their belief in their incapacity is reinforced. This belief then impacts our motivation to try further because trying to just reach failure is not worth our effort.
Besides the ADHD individual proving their own incapacity to themselves, their parents may punish them for their mistakes early in life and create a layer of belief that is contingent primarily on social feedback. Being diagnosed with mental illness is such a form of social feedback itself. If it were possible to learn from trial and error or to develop new skills to manage the way we interact with our environment, these identities like ADHD and failure lead us to believe that this is who we are, some sort of fixed person. These identities provide us with an explanation like “we are just born this way and there is no real solution except medicating our deviant physiology” (although not everyone believes in it this way). I disagree with this concept of identity but it is a popular notion. We define each other using these ideas that a person is repetitive in their choices, thinking, and so on.
Admittedly, not all cases are easy to classify. I have some control over my heartbeat, but it is impossible for me to reduce it to 10 beats per minute. Is the number of times my heart beats per minute a constraint or a choice? The distinction between constraints and preferences suggests an illuminating test for ambiguous cases: Can we change a person’s behavior purely by changing his incentives? If we can, it follows that the person was able to act differently all along, but preferred not to; his condition is a matter of preference, not constraint. I will refer to this as the ‘Gun-to-the-Head Test’. If suddenly pointing a gun at alcoholics induces them to stop drinking, then evidently sober behavior was in their choice set all along. Conversely, if a gun-to-the-head fails to change a person’s behavior, it is highly likely (though not necessarily true) that you are literally asking the impossible.
In my most recent essay on schizophrenia, Making Sense of Madness, I brought up how incentive saliency may be implicated in the development of delusions and hallucinations. In essence, we have motivated perceptions and beliefs. Similarly, I argued that dissociation is sometimes motivated by self-protection during stress. This may work by hijacking our attention, directing us away from the pain or stress as if to undergo spontaneous meditation. Despite that the urges to avoid pain or chase pleasure are motivations, a gun-to-the-head test would likely not change a person’s beliefs or tendency to dissociate as a cope. Perhaps a person might even develop dissociation to cope with the gun-to-the-head test because of the incentive to escape the fear or pain.
In the case of an ADHD individual, I could imagine a person bargaining with the gun holder, suggesting to them that they truly have constraints and that this isn’t fair. Perhaps when the only solution to escape the gun is to comply, then the individual would change behaviors. I’m not convinced that you could change beliefs by using a gun to the head, but I am convinced that you can use incentives to change people’s beliefs. A gun to the head will simply make them lie about their beliefs I would expect. It is a loophole solution that fixes the gun issue without having to change one’s beliefs. Even the belief that there are loophole solutions would cause non-compliance in the gun situation. Alternatively, the belief that there are no solutions might cause the person to submit and accept death, regardless of whether they actually have solutions that could be employed if their beliefs permitted such.
This ties back to the idea that we lose motivation when we believe the goal is unattainable. You could hold a gun to a person’s head and tell them they must solve space travel and the person may even have the capacity to eventually solve it, but if the person does not believe that they can solve space travel, they will give up and accept loss I suspect. This doesn’t really prove that space travel is impossible nor does it prove that the individual does not have the capacity to solve it. It is an issue related to one’s belief about what is possible. How we believe about achieving teleportation, causing belief-change, and the nature of mental illness all impact how reality plays out. We play out reality in the ways that conform to our beliefs which reinforces our beliefs when reality conforms to our predictions.
Perhaps beliefs are sometimes constraints. Although to believe such is a constraint in itself.
Szasz and Caplan both says that mental illnesses are attempts to stigmatize those with unusual preferences. I say that mental illnesses can reflect people’s genuine worries about a-thing-sort-of-like-a-budgetary-constraint afflicting them. Which of us is right?
Well, consider that about 95% of people who go to an outpatient psychiatrist do so of their own free choice. This is certainly the case with my own patients. They are people who have gotten tired with the constraints that mental illnesses put on their lives, come in and say “Doctor, please help me”, and I try to help them achieve whatever goals they have for themselves.
Just to introduce a bit more absurdity: for some reason, mentally healthy individuals struggle to admit themselves to mental hospitals and this may be a kind of constraint they have. We could try the gun-to-the-head test as a way to see if this is really a preference to avoid mental hospitals or a true constraint. Also, perhaps the 95% of people who go to an outpatient psychiatrist of their own free choice actually have more agency than mentally healthy people who fail to go to outpatient psychiatrists.
In reality, we have preferences that conflict with each other. It is easy to see why most mentally healthy people would not have a preference to admit themselves to a mental hospital. Such a preference also exists within mentally unhealthy people but there is an added preference the person has to deal with their mental health symptoms too. Our motivations and preferences are in constant conflict. People may have genes that give them increased preference to admit themselves to mental hospitals that conflict with their also genetic preference to avoid them.
The conversation with Bryan and Scott gets into the role of genetics and mental illness. They both seem to agree on this. It is worth bringing up because I share this belief and it is important in how we look at mental health and genetics.
Caplan ends by noting that genetics and neurobiology cannot prove him wrong. Yes, weird preferences may be genetic, and they may be linked to weird neurobiology, but so are our normal preferences! There are genetic factors influencing schizophrenia, but there are also genetic factors influencing politics, religion, and extraversion. Yes, drugs can make you less schizophrenic, but they can also make you less extraverted.
I agree with Caplan’s last paragraph. We can’t prove him wrong with neurobiology alone. So let’s prove him wrong with philosophy, psychology, economics, and common sense.
Other things are probably partially genetic:
- An increased propensity to acquire different beliefs that impact our belief-related constraints.
- Being punished by parents via inherited tendency to not submit to authority or follow rules well enough (looking at you ADHD/ODD correlation).
- Different degree of willingness to admit onself to mental hospitals.
- Maybe almost everything just a little bit?
Scott mentions that Bryan’s claim that alcoholics would be driven by the preference to be an alcoholic over having a job, go to AA meetings, and then later feel guilty about all of it and attempt suicide. Bryan remarks on whether alcoholism is a disease and how this is used to justify alcoholic behavior:
(a) We don’t need to “fully explain alcoholic behavior” to admit that my story is often illuminating. “I have a disease” is a convenient excuse for bad behavior; indeed, it’s so convenient that heavy drinkers offer it so casually that they don’t experience it as deception.
(b) People often wish they had different preferences, but this hardly shows that what appear to be preferences are actually diseases. My original article neglected this issue, but this post addresses it in detail – and explains why it matters.
In previous essays, I have taken sides similar to (a), though I would say it is more complex than being the case that either people are always lying or never lying. I think that knowing that others believe you struggle with something outside of your control provides us with an undeniable justification that others will respect, giving us the power to exploit this. In the case of drug use, the incentive to exploit this may increase very greatly. If we strongly wish to consume drugs and avoid some negative social consequences we can argue that we are helpless to the drug, which we are rewarded for persuading others. Perhaps Scott believes that drug users are more incentivized to follow their value system that says “do not lie” more than they care about consuming their drug. Although I think this kind of lie is ubiquitous in society and it isn’t even the drug user who is particularly prone.
Another aspect about (a) is that this could fall into delusion territory. One could be lying but they could also be using motivated reasoning that follows incentives besides truth. Truth is only valuable because it allows us to better navigate the world with precision. But delusions are also valuable for social purposes so truth isn’t the only incentive present. You might think about biases in science this way too. Funding and reputation become incentives that might actually have more selfish utility than proper science. Honest science might be valuable for people suffering a disease being studied but it isn’t valuable for the actual scientist beyond how it affects their reputation, personal interests, and survival. Truth really only matters because it impacts our survival or benefit and falsehoods can provide competing incentives too.
Being delusional is also more rewarding than lying since lying gives us anti-incentives like guilt. Intellectual cultures aim to attach guilt with delusional thinking processes and motivated reasoning. Though, this hasn’t really spread to the general populace as much as the guilt for lying meme has.
The idea that our preferences conflict with each other is at the root of this problem (b). We can both want to drink alcohol and want a safe job or conformity and the pain that results from these conflicting desires can hurt so much that we wish to die rather than to try to change our desires through rehabilitation.
Another component is that people’s preferences/desires may wildly fluctuate from context to context. People often crave heroin much less while they are on it whereas a week into heroin withdrawals they will highly prefer to have heroin.
On the topic of delusions responding to incentives Byran says:
At least for many delusions, the fact that you would try to feign recovery shows that your degree of irrationality – not just outward behavior – is incentive-sensitive. Nash is once again an excellent example. ‘I thought I was a Messianic godlike figure with secret ideas’, he tells us. ‘I became a person of delusionally influenced thinking but of relatively moderate behavior and thus tended to avoid hospitalization and the direct attention of psychiatrists’ (Nasar 1998: 335). But if Nash were literally constrained to see himself as a ‘godlike figure’, he would have imagined that he could free himself at any moment.21 He would be unable to grasp that – in reality – his freedom depended on a psychiatrist’s diagnosis, so he would have no motive to ‘beat the system’.
This idea that Nash does not truly believe that he is godlike is quite interesting. It may be because Nash’s thoughts are not motivated by the absolution of contradictions or truth-seeking but instead could be motivated by the rewarding title of godlikeness. The salience of the contradictions in “godlikeness” and its’ practical implications may be muted because of the way it essentially isn’t rewarding enough.
Another element comes back to this idea that attention and dissociation could be major factors in delusion formation. Here is a clip from a recent essay I wrote on this:
Delusional thinking may occur when we selectively dissociate from memories or learned ideas that are typically important in guiding our conclusions about reality. I’ve explored this in Is Delusion Ordinary?. Our motivation to believe something could bias which memories we attend to and which that we neglect, so that we pay attention to the memories that support our conclusion, essentially a confirmation bias.
Many delusions likely involve the potential suffering that could occur if the delusion were not believed. Again, this is like negative reinforcement. This might sound strange, but consider the case of debating someone in public. You’ve likely observed cases where an individual was stubbornly defending their position on a topic to the point of being delusional. This may stem from the high cost of admitting defeat. These sort of delusions likely occur when the cost of admitting defeat is horribly painful, particularly when admitting defeat is to admit you are stupid or insane. Abusing people for having bad ideas might actually facilitate the development of delusions as a dissociative coping mechanism. If your delusional belief is right, your opponent can be disregarded as crazy which invalidates their conclusion that you are stupid. It is probably the case that early life experiences involving being shamed for being wrong can lead to such delusion proneness. This may even be a major driving factor in the political polarization we see today, since both sides intellectually threaten each other.
Some researchers believe that hypersalience of evidence for beliefs drives delusional processes (Balzan et al., 2013). In essence, hypersalience of stimuli means that the stimuli are louder. Different forms of altered states may arise from stimuli being abnormally loud or quiet, producing hallucinations or delusions. Perhaps psychosis isn’t about stimuli being abnormally salient, but actually the salience of everything is reduced to a degree that allows more “choice” to what we attend to, which might be more strongly driven by motivations rather than overt loudness or importance of stimuli. To make sense of this, consider how surprising and loud events might distract your attention and force you to observe. Those with generally reduced loudness-of-stimuli might be driven more by their thoughts or imaginations and ignore stimuli that others do not, causing aberration in perception and thoughts.
The debate between Scott and Bryan seems to be touching on the idea of free will and the hypercomplexities of decision-making processes. The topic of free will and choice gets somewhat absurd in my mind and it is difficult to address that aspect.
To view mental illnesses as preferences or diseases seems to be oversimplified. I am not sure that we can generalize or reduce these situations to such broad statements. If we dissect any given mental illness there will be an endless list of factors involved that also change moment to moment based on the context.
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