I.

Bryan Caplan has a 2006 paper arguing that economic theory casts doubt on the consensus view of psychiatric disease. He writes:

Economists recognize the benefits of specialization. Only with hestitation, then, can economists focus their attention on an unfamiliar discipline and conclude that experienced professionals have been making elementary mistakes. However inconsistent psychiatry’s main theses seem to be with basic consumer theory, one might think it foolhardy to conclude that they are wrong. At the same time, economists also recognize not only that rentseeking is a ubiquitous force, but that most rent-seekers create and internalize public-interested justifications for their activities. It is not overreaching for economists to criticize domestic auto makers’ arguments for protectionism. The auto makers know more about the details of their own industry, but economists are better at interpreting those details. Equally importantly, economists are trained to consider the costs of a policy for everyone in society, not merely groups with the most political influence. From a rent-seeking perspective, skepticism about psychiatry is common sense. Rent-seeking is only a side activity for the auto industry, but it lies at the core of psychiatry.

Calling someone a rent-seeker is sort of an economist’s way of telling them to die in a fire, so I feel honor-bound to respond.

As best I can tell, Caplan’s argument goes like this:

Consumer theory distinguishes between two different reasons why someone might not buy a Ferrari – budget constraints (they can’t afford one) and preferences (they don’t want one, or they want other things more). Physical diseases seem much like budget constraints – the reason a paralyzed person can’t run a marathon is because it’s beyond her abilities, simply impossible. Psychiatric diseases seem more like preferences. There’s nothing obvious stopping an alcoholic from quitting booze and there’s nothing obvious preventing someone with ADHD from sitting still and paying attention. Therefore they are best modeled as people with unusual preferences – the one with a preference for booze over normal activities like holding down a job, the other with a high dispreference for sitting still and attending classes. But lots of people have weird preferences. Therefore, psychiatric diseases should be thought of as within the broad spectrum of normal variation, rather than as analogous to physical diseases.

He compares this to the work of Thomas Szaszszszsz, who proposes that psychiatry is an inherently political enterprise that works to delegitimize people with unusual preferences. For example, until the 1970s homosexuality was considered a psychiatric disease, and now it is considered an uncommon but legitimate preference. In the past being transgender was considered a psychiatric disease, but now many people are moving toward considering it an uncommon but legitimate preference. In each case, when society thinks that a preference is gross, or anti-social, or so extreme that they can’t imagine themselves having it, they shout “Psychiatric disease!” and then they can stick anyone who offends them in mental hospitals; if the preference becomes more legitimate, they retreat and say “Guess those ones weren’t psychiatric diseases after all, but we’re still 100% sure all the other ones are”. Caplan says that instead of these constant mini-retreats we should just admit that all psychiatric diseases are unusual preferences.

He admits that he’s making his job too easy with examples like alcoholism, and that something like schizophrenia would make a harder test case. But, he asks, what is schizophrenia? Delusions and hallucinations. Delusions may be a preference to have a weird belief – for example, somebody might feel trivial and neglected, so in order to make themselves feel important they cook up a paranoid conspiracy theory where the FBI, CIA, and Freemasons are all after them because of how important they are. Wanting to believe that the government is after you is a weird preference but, Caplan insists, nevertheless still a preference. As for hallucinations, sure, schizophrenic people say they hear voices, but we all kind of hear internal voices in the sense of “hear ourselves thinking in our head”, and schizophrenics must just be people who prefer to explain those in very vivid external terms. Visual hallucinations are the same way – we all have an imagination, but some of us react to our imaginations differently than others.

Therefore, all psychiatric diseases can be conceptualized in the form of preferences. This makes them very different to physical diseases, which are budgetary limitations, and we should stop saying they’re the same thing and locking mentally ill people up and having all of these rent-seeking psychiatrists around saying they can “cure” them.

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.

II.

Let’s start with preferences vs. budgetary constraints.

Alice has always had problems concentrating in school. Now she’s older and she hops between a couple of different part-time jobs. She frequently calls in sick because she feels like she doesn’t have enough energy to go into work that day, and when she does work her mind isn’t really on her projects. When she gets home, she mostly just lies in bed and sleeps. She goes to a psychiatrist who diagnoses her with ADHD and depression.

Bob is a high-powered corporate executive who rose to become Vice-President of his big Fortune 500 company. When he gets home after working 14 hour days, he trains toward his dream of running the Boston Marathon. Alas, this week Bob has the flu. He finds that he’s really tired all the time, and he usually feels exhausted at work and goes home after lunch; when he stays, he finds that his mind just can’t concentrate on what he’s doing. Yesterday he stayed home from work entirely because he didn’t feel like he had the energy. And when he gets home, instead of doing his customary 16 mile run he just lies in bed all day. His doctor tells him that he has the flu and is expected to recover soon.

At least for this week Alice and Bob are pretty similar. They’d both like to be able to work long hours, concentrate hard, and stay active after work. Instead they’re both working short hours, calling in sick, failing to concentrate, and lying in bed all day.

But for some reason, Bryan calls Alice’s problem “different preferences” and Bob’s problem “budgetary constraints”, even though they’re presenting exactly the same way! It doesn’t look like he’s “diagnosing” which side of the consumer theory dichotomy they’re on by their symptoms, but rather by his assumptions about the causes.

And his assumptions about the causes may be wrong. Bob’s issues are probably caused by what we call “sickness behavior”, a chemical defense in which the immune system notices an infection and releases cytokines telling your brain to avoid action and conserve energy in order to help with recovery. But one of the theories of depression I have found most plausible is that it’s a malfunctioning of sickness behavior – you’re not necessarily really sick, but your immune system releases its “stop acting and lie in bed all day so we can recover” chemicals anyway. If flu and depression have the same proximal cause, and the same effects on your life, where does Bryan draw the budget/preferences line?

For that matter, does Bryan ever get tired? I mean, suppose he is up very late one night and then has to go to work on only an hour of sleep. If he’s like the rest of us, he probably does a terrible job, can’t concentrate, and maybe rushes through things to get home early so he can catch a nap. Is this a budgetary constraint, or different preferences? In one sense it seems budgetary – he is lacking a resource (sleep? mental energy?) that would allow him to do a good job if he had it. In another sense it is clearly preferential – he places much less value in working hard and much more value in rushing home to get a nap.

Either way, this seems like a fruitful way to think about conditions like ADHD. Someone with ADHD, like someone who’s working on an hour of sleep, finds themselves miserable and unable to focus. If we call this a budgetary constraint, Bryan’s whole argument comes tumbling down. But if we call it a preference, then it’s a very strange type of preference, one where the usual method of “oh, great, you’re doing what you prefer!” is entirely the wrong approach.

In the case of the sleep-deprived person, their “new set of preferences” seems like a malign and unpleasant condition inflicted on them by an external source – namely, their sleeplessness. It’s certainly not “what they prefer” in the sense of “oh, great, he’s doing what he prefers, now he’s self-actualized and all is right with the world.” Instead, we admit that it’s a problem, they admit that it’s a problem, and we prescribe a biological cure – more sleep.

Or here’s another example. Suppose while you are asleep I inject you with a little machine that constantly releases interferon into your bloodstream – interferon being a hepatitis medication notorious for causing deep depression as a side effect. You become depressed, and your preferences change from “work and spend time with my friends” to “lie in bed all day”. But a helpful wizard gives you a powerful antidote. If you take the antidote every day, the interferon is rendered harmless and you are as active as ever. Unfortunately, you run out of antidote, and you lie in bed all day.

So: is your lying in bed all day a preference, or a budgetary constraint caused by shortage of antidote?

My answer: dichotomies sometimes break down outside a certain scope. I enjoy reading Bryan’s posts about immigration, which often compare immigrants to natives along some axis. Immigrant vs. native is a useful dichotomy for a lot of purposes. But: were the guys on the Mayflower immigrants or natives? Were slaves abducted from Africa to work on plantations immigrants or natives? Were the couple thousand residents of California who went to bed as Mexicans the night before the Treaty of Guadalupe Hidalgo and woke up as Americans the next morning immigrants or natives? What about migratory birds? The number three? The Devil?

I propose that the preference/budget distinction is a bad way of dealing with anything more complicated than which brand of shampoo to buy. We intuitively talk about our choices as if there were some kind of “mental energy” that allows one to pursue difficult preferences, and I discuss some ways this confuses our intuitive notion of budgeting in Parts II and III here. You don’t have to accept any particular framing of this, but to sweep the entire problem under the rug is to ignore reality because you’re trying to squeeze all of human experience into a theory about shampoo.

III.

If there’s not a lot of difference between preferences and budgetary constraints, what does that say about the relevance of Thomas Szasz?

(By relevance, I mean relevance to the modern day; he wrote in the 1960s and what he wrote was very possibly more true then than it is now. Possibly played a big part in making the things he wrote about less true, and should be celebrated for this. But I’ll concentrate on the present.)

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.

About 50% of people who go to inpatient psychiatric facilities also go of their own free choice. The rest, assuming everyone’s following the legal system and the appropriate ethical guidelines, are people who are “dangers to themselves or others”. I admit, it takes a controversial value judgment to decide people shouldn’t be allowed to be dangerous toward themselves – though I think in some cases that judgment can be justified. And I admit that “danger to others” can sometimes be stretched to the point where if a psychiatrist wants to commit someone they can probably make up a justification. But these implementation problems are a heck of a long way from Caplan and Szasz’s theory of “psychiatry is just a project about finding weird people and locking them up.”

The psychiatric profession will never live down the thing about homosexuality; I fully expect that in 5000 AD someone will still be complaining that we can’t stigmatize entities infected with superintelligent self-replicating memetic viruses, because DSM-II listed homosexuality as a psychiatric disease. But there’s still a chance to rebut the thing about transgender, so let me quote from the APA website’s discussion of the topic:

The [new DSM criteria] underscore that being transgender is not a disorder in itself: Treatment only is considered for transgender people who experience gender dysphoria — a feeling of intense distress that one’s body is not consistent with the gender he or she feels they are, explains Walter Bockting, PhD, a clinical psychologist and co-director of the LGBT Health Initiative at Columbia University Medical Center.

In other words, the decision about whether transgender people need psychiatric help is left up to – transgender people. If they don’t want it, they don’t have to have it. If they do want it, the option is open to them and their condition is recognized as a legitimate reason to seek help that insurance companies will support. I myself have treated exactly one patient for gender dysphoria. She was so depressed about her gender that she was considering suicide. I gave her some antidepressants, some supportive therapy, and some information about local support groups and sex-change professionals. Then I billed her insurance company for gender dysphoria treatment and got a check. Truly everyone involved is Worse Than Hitler.

IV.

Caplan admits that some mentally ill people seek help voluntarily and are among the most vocal proponents of the “real disease” theory. In order to shoehorn this into his preference-budget dichotomy, he theorizes that this is an attempt at deception. For example, alcoholics’ insistence that they cannot resist drinking alcohol is deceptive:

From an economic point of view, however, what is so puzzling about a person who prefers consuming alcohol to career success or family stability? Life is full of trade-offs. The fact that most of us would make a different choice is hardly evidence of irrationality. Neither is the fact that few alcoholics will admit their priorities; expressing regret and a desire to change is an excellent way to deflect social and legal sanctions.

But in order to fully explain alcoholic behavior, we have to take this theory exceptionally far. Consider a typical alcoholic drinks for several years, then “hits bottom”, goes sober, and joins Alcoholics Anonymous. He attends AA meetings three times a week for three years, then has a really bad day and binges on alcohol. Afterwards he is so embarrassed that he attempts suicide, but is rushed to the hospital and resuscitated successfully. After that he goes back to his AA meetings.

Does this man have a preference for going to AA meetings three times a week for several years then getting really drunk then attempting suicide? That’s a weird preference to have. Does he have a preference to drink, and in order to be socially acceptable he ‘covers up’ his one episode of binge drinking by years of AA meetings and a serious suicide attempt which he secretly knows will fail? That is a pretty disproportionately big web of lies, especially when probably no one would blame him for binge drinking one night one time.

If we’re willing to be this paranoid, we can basically prove or disprove anything. Bryan Caplan says he’s a libertarian, but my 9th grade Civics textbook says there are only two political parties, Democrats and Republicans. If Bryan says he’s in a third, he must just be trying to “deflect social and legal sanctions”. Maybe he’s secretly a Republican, but he wants to fit in to academic culture, so he says all of this stuff about “libertarianism” as a cover. His work writing hundreds of essays and some pretty decent books supporting his libertarian viewpoint are to maintain the credibility of his signal and throw us off the trail. Any donations he may have made to libertarian causes are the same…

…or we can be skeptical of textbooks that try to reduce things to simple dichotomies, whether that’s Democrat/Republican or preference/budget.

Caplan sort of flirts with admitting this:

Cooter and Ulen probably speak for many economists when they deny that the preferences of the severely mentally ill are well-ordered. But in fact, not only do individuals with mental disorders typically have transitive preferences; they usually have more definite and predictable orderings than the average person…it is also implausible to interpret most mental illness using a ‘hyperbolic discounting’ or ‘multiple selves’ model. These might fit a moderate drug user who says he ‘wants to quit’…but they do not fit the hard-core drug addict whose only wish is to be left alone to pursue his habit. The same holds for most serious mental disorders: they are considered serious in large part because the affected individual continues to pursue the same objectionable behavior over time with no desire to change.

But if we take that middle part seriously he is ceding me 99.9% of the ground without remarking on it. Most people with mental disorders and substance abuse disorders wants to get rid of their disorder or at least alleviate the worst parts of it. If you are willing to accept complicated “multiple selves” models for those, then that is what you should be using to model mental disorders, not the simple consumer price theory.

And the others? The alcoholic who says “Yup, I’m drinking myself to death and you can’t stop me?” I agree that it is in some sense rational. It is rational because that person has so many problems that drinking alcohol becomes more pleasant than dealing with them. Often, these problems are related to psychiatric issues – for example, many people with PTSD become alcoholics because alcohol helps them briefly forget their traumatic memories. There are many people who say they don’t want help with their drinking problem because they expect “help” to mean “take away the alcohol but give them nothing in exchange”. If “help” meant “replace the alcohol with some healthier coping mechanism that works just as well”, many of these people would take it in a heartbeat. I realize this doesn’t quite disprove Caplan’s thesis for this relatively small group of alcoholics, but I think it’s important to remember that “preference” is different from “they’re doing what they want and all is well”.

V.

Finally, Caplan moves into a discussion of schizophrenia. He says that hallucinations might just be people hearing their normal inner voice and seeing their usual inner imagination, but they choose to describe it differently:

Szasz similarly maintains that many alleged hallucinations are only eccentric descriptions of ordinary experience. To take the most common form, psychiatrists routinely equate ‘hearing voices’ with auditory hallucination. But when a person feels guilty, we often say that he hears the voice of conscience…to take a stronger case, the DSM treats ‘a voice keeping up a running commentary on the person’s behavior or thoughts’ as an exceptionally serious symptom. But this describes any person deliberating between major life options over an extended period of time. While these examples might seem to stretch the meaning of ‘hallucination’, it is the DSM that explicitly fails to distinguish whether the source of the voices is perceived as being inside or outside of the head.’

This makes sense, which is why every psychiatrist for the past century has specifically asked patients whether that’s what’s happening before diagnosing them with anything. Any time a patient reports a hallucination to me, the first question I ask is whether they’re just embellishing on hearing an inner voice, or whether they actually heard an external voice clearly and distinctly the way they are hearing me talk to them right now. Sometimes they did just hear an inner voice – this is especially common in OCD obsessions – but other times they tell me that no, it was definitely an external voice, totally different from their normal internal voice. Sometimes they thought at first it was a normal non-hallucinatory voice talking to them, and they got up to try to figure out who it was before they realized no one was around and it had to have been a hallucination.

This should not be surprising to anyone who has ever taken drugs, heard from people who took drugs, or been vaguely aware of the existence of drugs. Drugs can cause vivid, realistic hallucinations. Caplan says he doesn’t want to talk about neurobiology, and that’s all nice and well, but drugs provide a pretty good neurobiological proof of concept. LSD, which is infamous for its hallucinations, is a 5-HT2A agonist. You can treat schizophrenic hallucinations with Seroquel, which is a 5HT2A antagonist; placebo Seroquel doesn’t work nearly as well. Coincidence? I feel like at this point we’re getting into paranoid are-we-sure-anyone-is-a-libertarian territory again.

He then goes on to say that delusions might just be a preference to believe something, rather than actually believing it. There’s a lot of epistemological complexity here – can we believe something just because we prefer to believe it? If someone offered me $1 million to believe that Greenland is in the southern hemisphere, could I do it? I think not, but I think Caplan understands this and is accusing delusional people of just playing a sort of LARP where they act as if they’re in a much more interesting universe full of FBI agents and secret radios and the Devil. In favor of this, he describes how psychotic people can sometimes adjust their thinking and actions when they have incentive to do so. For example, he talks about some psychiatric inpatients denying their delusional beliefs in order to avoid electroconvulsive therapy.

I don’t think the ability of psychiatric inpatients to hide their condition in response to incentives changes things much. I firmly and genuinely believe that Greenland is in the northern hemisphere, but if someone threatened to give me old-timey scary electroconvulsive therapy for believing this, I would tell them it was however far south they wanted it to be. This doesn’t mean my belief about Greenland is insincere, it just means I can think strategically. That even very deeply mentally ill people can think strategically can sometimes be surprising, but no one who has worked with them would deny it can be true.

On the other hand, some of them can’t think strategically. I remember one patient who was very angry at being involuntarily kept in the hospital who would come up to me every day and start screaming at me that if I didn’t let him out, his friends in the highest level of the government were going to revoke my medical license – later this escalated to “kill me”. Spoiler – this is a really bad way to get out of a psychiatric institution. I even told him this was a really bad way to get out of the psychiatric institution and he’d be making his case better by just leaving me alone. He kept finding me and screaming threats about his friends in the government anyway. I can’t tell you for sure what the difference is between people who think strategically and who don’t think strategically – it’s certainly not as simple as “people with illness X are strategic, but people with illness Y aren’t”, but it is certainly a pretty obvious dichotomy.

This patient’s story continues – I put him on antipsychotics, and after two weeks he said he was feeling much better, no longer talked about his friends in the government, and actually thanked me for treating him. I discharged him and as far as I know he’s still taking those medications. If schizophrenia was a preference, this would be strange: he prefers to be schizophrenic, he knows that taking medications will make him less schizophrenic, but he keeps taking them anyway! Since many people like him become schizophrenic, keep taking their antipsychotic medication, and then become better – leaving them much as they were before they became schizophrenic – Caplan’s theory can only theorize that they have a base-level preference for being on antipsychotic drugs. This is a terrible preference to have – such drugs often have bad side effects and make you feel miserable. Surely it makes more sense to believe they have a problem which they don’t like and which the antipsychotics successfully treat?

(yes, there are also many schizophrenic people who don’t voluntarily take their medication. But there are also many people with high blood pressure who don’t take their medication, and antipsychotics are way less pleasant than antihypertensives)

One more thing. Although hallucinations and delusions are the flashiest symptoms of schizophrenia, they are by no means the only ones or even the most important. Many schizophrenics have what’s called “formal thought disorder”, which means their thoughts go in weird directions. A classic example is the tangential person, who will get so distracted they can’t finish a thought. “Tell me how the medication is working?” “Well, I took my medication this morning, after waking up, because I had a bad dream last night, I can’t remember exactly what it was about, I think there was a dog in it, my favorite kind of dog is a Labrador Retriever, I think they’re from Canada, I was in Canada once, it was really cold.” Another kind is the clang, where they connect thoughts based on sound rather than meaning: “I took my medication this morning, it was a warning, a warning of doom, coming at noon with the moon.” This is, as far as I can tell, not something that schizophrenics can successfully “tone down” when asked to do so, based on informal experiments where I ask schizophrenic people to speak normally and tell them that I am more likely to let them out of the hospital if they can form a coherent sentence. This avoids the strategic issues involved in “covering up” hallucinations. Sure, you can always have hallucinations but say you aren’t, but it’s really hard to fake not having a formal thought disorder if you have one, and indeed when a schizophrenic person has a formal thought disorder it’s there to stay until they are treated.

So as far as I can tell schizophrenia includes real hallucinations and delusions, real formal thought issues that the patient usually cannot control, and often the patient is unhappy with it and will willingly take medication to get rid of it. Combined with the neurobiological evidence, the genetic evidence, and the pharmacological evidence, I don’t think calling it “different preferences” is remotely viable.

The Caplan paper is from 2006. I don’t know if he still believes it. And I don’t know if anyone else holds this particular view. But I still meet the occasional Zsazsaian, and general feelings that psychiatric illness isn’t “real illness” are still common. I don’t think it’s a very tenable position and I don’t think this paper does much to support it.

EDIT: I previously wrote in more detail about the difference between “disease” and “normal variation” here.