Long-troubled actress Amanda Bynes has apparently been checked into a psychiatric facility to address the mental illness that has plagued her for years. She’s reported to have been wandering naked outdoors when she flagged down a car and asked for help, telling the driver that she was having a psychotic episode. People are naturally grateful that she was able to request help in that way, but I’m also seeing a lot of confusion. Which is understandable; a psychotic person being cognizant enough to request help is out of step with how most people conceive of serious mental illness. But psychosis is more complex and multivariate than most people think, and I hope this incident prompts people to broaden their understanding of the condition. The mind is complicated, and so are the ways in which it breaks down.
Too much money and celebrity are the opposite of defenses - they massively increase the odds you'll suffer mental illness and/or have a terrible quality of life.
Bipolar disorder has a significant genetic component. I agree that celebrity can be a contributing factor--as celebrities may tend to use drugs heavily, and drug use tends to really exacerbate the condition.
I suspect without any evidence that stress plays a major role, and there are certain types of stress in being a celebrity.
Then again, there is a lot of stress on Wall Street, but I haven't run into too many schizophrenic investment bankers, just cokehead assholes. Maybe the difference is that it's easier for a celebrity to find plenty of enablers if they wish to do so, and not enough people who will call out bad or ill behavior.
As someone approaching 2 decades on wall street and who used to do a lot of coke... not really. It's now seen as pretty low status, sort of like smoking.
There will be lines during bonus week at shitty brokerages, and maybe some ex vampire squids still have a habit. But most have moved on.
Great post. We often use the term insight in clinical practice. This can be multi-faceted - a person can have varying degrees of insight into their symptoms, their mental health diagnosis and need for treatment.
One illustration of your point—I am personally always struck by the fact that severe alcoholics can have insight that is as bad or worse than those with chronic psychotic disorders. The whole thing is an interesting and nuanced topic.
I remember one of my attendings in residency, when teaching about the mental status exam, told us half-jokingly, "Nobody has 'good' insight. They have 'fair' insight at best. You and I have 'fair' insight. Maybe if you are fully psychoanalyzed or enlightened you have good insight. Otherwise insight varies from poor-to-fair." Probably not literally true, but in retrospect it is a good reminder not to be too confident in our own self-knowledge.
The story has stuck with me for days, including the story of Shina, one of the people who lives in a tent. She knows she has delusions, and tells the reporter—but also believes many of them sincerely. She also had practical survival skills and helped the others.
Liberals are always debating whether people like Shina should be permitted to live in a tent or forced into services. I admit I’m on team services, but it’s complicated when someone has delusional beliefs but is otherwise functioning.
"And then there was Keisha, barely out of her teens, who had skittered around the encampment like a scared cat, wary of everyone, carrying a few old dolls and crying sometimes. Joel had tried to watch out for her, offering her water or a few minutes inside whenever she was upset. But one weekend when he wasn’t around, the temperature was 115 degrees, and she lay down on the curb near his gallery and died of heat exposure and dehydration."
Jesus Fucking Christ.
At least somebody at the Times still does real journalism.
Well said! I’ve never seen a problem with tent cities per se but when I was in NYC a couple years ago, I was eating at an outdoor restaurant and saw a homeless man walk up and start eating out of a trash can! Then, to make it even worse, the waitress just asked us to just look away... but most people have a natural reaction to help others in distress and ever since seeing that I don’t think there’s anything wrong with the government relocating people like that for their own sake! It’s disturbing to think that some homeless people may be chronically homeless because they’re out of their minds and perhaps a more direct and forceful solution is in order to address the homelessness crisis and try and get people back to health and happiness! No one in their right mind wants to live in a tent on the street!
The problem with tent cities is lack of basic sanitation. No toilets, no showers, dishwashing facilities or laundry. Tents are not insulated and therefore don't provide protection from extreme heat of cold.
They do provide a sense of privacy which is important.
yes, good point! I guess what I mean when I say “I’ve never seen a problem with tent cities” is I don’t think the government should make homelessness illegal but I also don’t think too much tolerance or turning a blind eye to destructive behavior is a winning strategy. A healthy society has people who are housed with a community that cares.
Another anecdote on mental health. When I was a kid, around 1960, my closest friends were twins who lived across the street. One day their dad, who was a Cornell professor, disappeared, sent to what was then one of several NY institutions to treat the mentally disturbed, in his case in Willard, NY. He reappeared in six months and went on to a productive career and happy life. The institution he was sent to and all others in New York were later closed on the grounds the insane would be better off living among us. This has turned out to be insane.
There’s still a lot of abuse and profiteering in the mental health industry, and in this age of deinstitutionalization, a risk to society is that people are under-treated or never treated at all. Thanks for sharing and I’m glad the story had a happy ending.
“ Liberals are always debating whether people like Shina should be permitted to live in a tent or forced into services.”
I’ve asked this before but where are the conservatives saying bring back the state hospitals? I haven’t gotten an answer. It seems there is more than enough blame to go around.
Any newspaper comment section about this issue is about 50% blaming it on Reagan, which is probably polarizing it unnecessarily, if your goal is fixing the problem and not just getting thumbs up. (Didn't JFK get the ball rolling on deinstitutionalization? I don't know, but in any case I'm fine blaming it on whoever to get the social incentives right to make people want to get it fixed.)
I've become more swayed to the virtues of involuntary holds in cases of severe mental illness because of Freddie, but in my city of Toronto, they simply rip up the tents and tell people to go to shelters, where there often isn't room (and when there is, it's often a more unpleasant experience than tents, they often require you to abandon pets and most/all personal belongings, and can cause their condition to get worse).
I was talking to someone who told me that he has a homeless friend who is addicted to drugs, and this man deliberately ODs and has him call 911 so he can go to the ER where there's food and a warm bed.
One issue is that for many of these people life outside a secure institutional setting just isn’t possible. Some people are just so mentally ill and/or just so susceptible to substance abuse they simply can’t function in society.
A powerfully illuminating and empathetic piece that serendipitously allows me to discuss with an actor in a play this potential for a character's consciousness that he is having a psychotic episode.
Great stuff as usual, thanks. There is a commercial, I forgot exactly which group sponsors it, but it shows a man crossing the street, encountering himself, and then getting into a fight with himself. It is moving to me, and especially more now because of reading your work on mental illness.
I wonder if there is something to how it seems some really great art is associated with mental illness. Maybe the more frequent and acute requirement at self examination gives someone a greater insight into the human condition. I wouldn't say it's a pre-requisite for good art, or a necessary outcome of a mental illness, but there seems to be a connection there. I know that for me as I get older, self examination, knowing oneself, seems to be the best way to understand the world.
“This may sound weird, but what can happen over time is that you get better at being psychotic.” I think this is an amazing opinion and accurate perspective! Obviously what happened to Amanda is tragic but I constantly hear rather cynical commentary on mental health conditions and that they “can’t be cured”. I love your article because it highlights that while psychosis is serious, especially when it persists as in Amanda’s case, maybe she’s getting a little better because she wasn’t hurt, didn’t hurt anyone else, and asked for help herself. I really think content like yours will help “end the stigma” around mental illnesses like psychosis so that people like Amanda can be treated with the respect and dignity the deserve and hopefully get better! 🫶
"As I’ve mentioned before, the technical term is anosognosia - the inability of the sick to understand that they’re sick. Anosognosia is indeed very common among people with schizophrenia and schizoaffective disorder, but not universal, and while many bipolar patients experience the condition, most estimates I’ve seen suggest that a majority don’t".
My best friend will, most of the time, acknowledge that he has schizophrenia and that he has previously experienced hallucinations and paranoia, but for him, the main voice he hears is an exception this this, and //exploits// the fact that he has diagnosed schizophrenia to hoodwink family, friends and medical staff while continuing to torment him.
Also, in a given conversation, the degree to which he speaks about the owner of this voice as having a concrete embodied existence outside of his head, and to which he speaks about the voice as disembodied and inwardly experienced, can vary (often fairly quickly). It's hard to explain from the outside... but it's like his relationship to metaphor is different to that of most people without schizophrenia. It's definitely important to not think of hallucinations as just "a false overlay on top of empirically real reality" as they are clearly much more complicated than that.
I wonder what, if anything, this implies about AI alignment (partly because I wonder that about everything these days). Yes, sure, there's no ironclad reason to presume that specific aspects of human minds will generalize onto weird superpowered programs. But in my view the most believable AI failure modes sound a lot like how you describe psychotic episodes: thoughts getting lost in themselves; obsessive itches taking over ever-increasingly from rational behavior as real-world feedback fades away; etc.
On the one hand, it's gratifying that minds tend to somewhat recognize when they're misfiring in this way, even as they continue to misfire; i.e. that "meta-rationality" can make sense to human-like minds when the rubber hits the road. On the other, it's worrisome that these tendencies may come and go, in unpredictable waves, and that, at least for humans, we have serious trouble debugging the root cause, even when we solve the specific crisis and offer general diagnoses, tips, resources, etc.
I tend to think this is the sort of failure mode that will characterize near-term worrisome AIs, rather than the issue being like paperclip maximizers. In other words, there seem to be reasons to believe that the most relevant issues will involve "inner misalignment" (learning the wrong heuristics to achieve the right goal), rather than "outer misalignment" (learning, with perfect clarity, the wrong goal). Think of it like how evolution taught us to pursue evolutionary fitness by liking sugar, and being horny, and so forth, because in our ancestral environment these were good and easy strategies to focus on, but now they probably harm our ability to propagate our genes (or at least easily end up getting hacked with activities which evolution would view as psychotic, like non-procreative sex).
In other words, I think the issue won't be that AIs don't learn to care about us -- "human persons" is a very natural abstraction to focus on in their training process -- just as the human species obviously learned to care about our relatives (especially our offspring) despite not having any understanding of DNA until quite recently. But think of all the ways in which parents can fail horribly by caring about their kids way too much (the failure modes I'm thinking of sound a lot like your description of psychosis, but obviously in a much less acute or medicalized way). Or think about how dogs can be optimized to just hijack our impulses to rear cute things, whereas kids have to be optimized to produce kids of their own (or else their genes stop showing up in the human story); so dogs can outcompete kids in this way, precisely as they become completely unfit on their own (think of e.g. how dependent pugs are), hence the fact that there are now more dogs than children in the US.
Here's an I think apropos quote (from https://cebk.substack.com/ [shameless self-promotion]) about how horribly wrong this can go; if the Bing chatbot's alarming hallucinations are any indication of what happens when AIs get unleashed on us, I think this could get bad fast:
You can evaluate whether some advice sounds good within a few seconds; however, you’ll need about a month—i.e. a few million seconds—to actually test out whether it works. Thus, if chatbots are trained by seeking reward, then those that focus on flattering our society’s vapid sensibilities will “evolve” about a million times faster than those that offer us harsh but useful truths (to the extent that reinforcement learning is like natural selection). That’s a huge advantage! If biological evolution had been sped up a million-fold, then dinosaurs would’ve first emerged around 1800, and would’ve gone extinct around 1960. Other forms of machine learning seem even more subject to this extreme social desirability bias: for instance, GPT-style transformer-based attention-only self-supervised prediction models only learn what the text corpus they’re trained on is likely to say about our world, not what’s actually true of it. And because language is already an incredibly effective compression of reality, language programs are likely to stay in control of AI progress.
I don't think language is anywhere near effective at compressing reality - it is just the least worst option we have. Even true masters of language often have a hard time expressing themselves accurately.
Thanks for your continued discussion on mental illness. Regarding involuntary holds, this article discusses pink slips and expanding its usage to severe alcohol and drug addictions. Given the Dayton area's high use of methamphetamines and their influence on neuro functioning with chronic use, it's likely there are co-occurring conditions though I'm not familiar with specifics for methamphetamine use and psychotic disorders (vs depression, anxiety, etc). I'd appreciate your thoughts or if you can point me toward more literature on "pink slips" in general. Thanks!
This makes sense to me. I have never had to deal with mental illness, but it has always seemed that the idea that the mind was a unitary entity was not really that true.
I think people understand this when it comes to urges. Your "rational" mind knows you are on a diet, but part of you still wants a cookie and they fight it out. I tend to think that even your rational mind is subject to conflict. Part of you wants to be on a diet, part of you wants a cookie, and part of you is coming up with ways that you can eat a cookie while still believing you are on a diet.
Years ago, I read a book "Getting to Yes," which was about various negotiation techniques that can make the other side more open to accepting or sticking with you view. I never found it super helpful in negotiating, but a lot of the tricks, e.g. getting them announce a favorable position, have always struck me as a good way to negotiate among myself. I could see someone with a psychotic disorder learning to do the same thing to ensure that, when they are having issues, they still can get themself to get help.
Evaluating insight into their condition when patients try to leave against medical advice can be very interesting. All they really have to say is that they appreciate the doctor thinks they're at risk by leaving but they're willing to take that chance. If they're not organized enough to say something like that, they have to stay.
Although the meaning of anosognosia is specific to clinically-diagnosed psychiatric conditions, I see it as a common and growing trait in modern humans that they are cognitively, emotionally or psychologically dysfunctional but not only don't know it and deny it, but point to others who "think" differently than them as being sick. And many of these people are societal and business leaders. The lack of self-awareness is ubiquitous and growing it seems. Cognitive dissonance results. It starts to feel like all of society is engulfed in some level of psychosis.
And related to self-aware psychosis, I think missing from this analysis is the impact of regular and heavy cannabis use. If ever we can recognize that psychological chemical imbalance contributes to brain dysfunction that contributes to psychological dysfunction, we have the evidence with the evidence of cause from cannabis.
I am starting to question if both, the trend toward more cognitive dissonance and lack of self-awareness AND the trend toward increased cannabis use, are related... and maybe supercharged by screen time on social media.
And then there are those with actual physical mental health challenges competing for treatment attention with those made "sick" by controllable externalizes.
Cannabis isn't the only substance that Amanda Byrnes was using when she began showing signs of severe mental illness. I also question how much of a recent "trend toward increased cannabis use" there is, when it's been very commonly used in the US for decades. A reality that appears to have only assumed crisis proportions in the minds of some observers in the aftermath of legalization efforts in some of the states.
Another substance that Amanda Byrnes was abusing- amphetamines, in the form of Adderall- has in fact undergone a dramatic rise in prescriptions in the past few years: "Prescriptions for a range of drugs to treat ADHD rose 19 percent, on average, between 2018 and 2022, according to a Post review of data from IQVIA, a health-care technology firm. Adderall and its generic versions, however, increased by 35 percent over that time, with the sharpest rise coming during the past two years." https://www.washingtonpost.com/business/2023/03/14/adderall-shortage-telehealth-prescriptions/
So the US is apparently back to the same per capita number of amphetamine prescriptions that were being issued in the 1950s and 1960s.
I can't say how much of this situation might be related to an increase in psychotic behavior in recent years, because I don't have any firm evidence that there has been such an increase. I don't have any data about any increase in "anosognosia" in the US population, either. So unlike yourself, I'm not ready to make any sure assertions about any of this stuff.
> Although the meaning of anosognosia is specific to clinically-diagnosed psychiatric conditions,
It's not; anosognosia applies to neurological and neurodegenerative conditions as well. Iirc it was created to refer to a more specific neurological deficit that affects self-perception due to localized neural damage (cf. visual agnosia and all the other -agnosias) and was widened to apply to conditions like Alzheimer's and anorexia where insight is impaired in a more general sense. A bit of a pet peeve of mine that this occurred since there's a good bit of difference between what's going on with "the man who mistook his wife for a hat" guy and what's going on in schizophrenia but oh well.
Obviously these are very different issues, but a lot of what you describe here lines up with my experiences with disordered eating (both my own and what I have observed in other people who struggle with them). I don't feel I have "healed" from my ED in the way that is often described in popular media, as much as I have learned how to live with and react differently to the "irrational mind" urges, thought patterns, habits and inner monologue that eventually lead to it.
This has been a double-edged sword for me, too -- on the one hand, I have gotten to a point where "learning to live with it" HAS allowed me to live a healthier and more fulfilling life, which feels an awful lot like healing/curing it. At the same time, "learning to live with it" can also look like "learning to hide it," "learning to go through the motions as a 'recovered person' while your mind continues to buzz under the surface," "learning to be just 'healed' enough to escape further treatment/scrutiny but not enough to fully move on," "learning how to game the system," "learning to parrot popular recovery mantras around people who you know scroll that corner of tiktok so you don't have to have a 100th conversation with them about HAES and diet culture" etc. (ok that last one is probably pretty specific to me...). I feel I have been all of these and more, sometimes at once, at different points in time, and while I'm pretty confident I'm headed in the right direction, it's hard to constantly wonder if I'm really on the "right path" or if I'm just doing further self harm. This is even more muddled thanks to modern information overload and access to too many opinions about the right and wrong ways to "be disordered" via the internet and social media.
Again I know these are different illnesses and am definitely not suggesting that my experiences are on the same level as those of someone who deals with psychosis. But this piece really resonated with me and I think this is a very useful framework for discussing mental illness and recovery.
Without presuming to speak for FdB or anyone who experiences psychosis, your description of your eating disorder “recovery” and comparison with his and Bynes’s experiences seems spot on from my pov.
I think it’s uncontroversial this day and age to say that ED and drug addiction are very similar forms of disordered thinking. In my teens and twenties, I burned my life down with heroin and cocaine, racked up felonies etc. I no longer partake of those particular molecules, but I constantly identify the same impulses in my thinking nowadays.
Your description of recovery as “learning to hide it”, go through the motions and heal just enough really resonates with me. I never really got sober, just moved from illegal, full-agonist opioids to partial-agonist prescription drugs for addicts. I learned how to modify dosing schedules to get what i wanted from the drug. When I eventually got off buprenorphine, I found other ways to legally modify my conscious experience that better-aligned with a life not so far on the outskirts of society.
Anyway, thanks for sharing your experience, it’s a helpful way to articulate my own to myself.
I have a delightful neighbour who has Myasthenia Gravis and serious mental health episodes when she sees and hears things. I’m retired as are several other neighbours or are stay at home moms. We watch out for her - but when and she is experiencing an episode, it is indeed difficult to see her being taken to the ER spitting fire at one of us who called for assistance. But when she comes out the other side, we all socialise in the backyard with girl talk and such.
My one experience with bad psychosis (and when I was diagnosed as bipolar) had me very delusional, with hallucinations, and hyper-real violent images playing in my head, which scared the shit out of me. Scared my young daughter too, when I told her I thought I was dying, in tears, and that I was sorry. Immediate access to quality care in these situations is crucial. I was able to see a good psychiatrist that day, because my wife, an MD, called him and said I wanted to go to the hospital. He said to come to his office, where he talked me through the worst of it, reassured me that the drugs would start working soon, and I ended up slowly, slowly recovering over the next couple months like it was a brain injury, without ever being admitted. Saw him once a week for a couple months, then less as time went on. I was definitely conscious and aware, just not at all hopeful that things would turn out well. To me, it felt like a delusional panic attack from hell.
Too much money and celebrity are the opposite of defenses - they massively increase the odds you'll suffer mental illness and/or have a terrible quality of life.
Bipolar disorder has a significant genetic component. I agree that celebrity can be a contributing factor--as celebrities may tend to use drugs heavily, and drug use tends to really exacerbate the condition.
I suspect without any evidence that stress plays a major role, and there are certain types of stress in being a celebrity.
Then again, there is a lot of stress on Wall Street, but I haven't run into too many schizophrenic investment bankers, just cokehead assholes. Maybe the difference is that it's easier for a celebrity to find plenty of enablers if they wish to do so, and not enough people who will call out bad or ill behavior.
You don't make it through your first year as an IB analyst with any mental health issues other than psychopathy.
Also, no one does coke anymore. There are much better and more effective drugs easily available.
This is not true - plenty of bankers still do coke.
As someone approaching 2 decades on wall street and who used to do a lot of coke... not really. It's now seen as pretty low status, sort of like smoking.
There will be lines during bonus week at shitty brokerages, and maybe some ex vampire squids still have a habit. But most have moved on.
I'll be more specific - Chicago bankers still do coke.
Yeah I’d probably still do coke if I lived in Chicago
Another great one, Freddie.
Great post. We often use the term insight in clinical practice. This can be multi-faceted - a person can have varying degrees of insight into their symptoms, their mental health diagnosis and need for treatment.
One illustration of your point—I am personally always struck by the fact that severe alcoholics can have insight that is as bad or worse than those with chronic psychotic disorders. The whole thing is an interesting and nuanced topic.
I remember one of my attendings in residency, when teaching about the mental status exam, told us half-jokingly, "Nobody has 'good' insight. They have 'fair' insight at best. You and I have 'fair' insight. Maybe if you are fully psychoanalyzed or enlightened you have good insight. Otherwise insight varies from poor-to-fair." Probably not literally true, but in retrospect it is a good reminder not to be too confident in our own self-knowledge.
Great piece. I think this is very hard for people to understand if they’ve never experienced psychosis, as I haven’t.
Did anyone else see the story in the NYT over the weekend about 2 sandwich shop owners overwhelmed by an encampment? https://www.nytimes.com/2023/03/19/us/phoenix-businesses-homelessness.html
The story has stuck with me for days, including the story of Shina, one of the people who lives in a tent. She knows she has delusions, and tells the reporter—but also believes many of them sincerely. She also had practical survival skills and helped the others.
Liberals are always debating whether people like Shina should be permitted to live in a tent or forced into services. I admit I’m on team services, but it’s complicated when someone has delusional beliefs but is otherwise functioning.
"And then there was Keisha, barely out of her teens, who had skittered around the encampment like a scared cat, wary of everyone, carrying a few old dolls and crying sometimes. Joel had tried to watch out for her, offering her water or a few minutes inside whenever she was upset. But one weekend when he wasn’t around, the temperature was 115 degrees, and she lay down on the curb near his gallery and died of heat exposure and dehydration."
Jesus Fucking Christ.
At least somebody at the Times still does real journalism.
"...it’s complicated when someone has delusional beliefs but is otherwise functioning".
The problem is that often it all works out and then suddenly it doesn't.
Well said! I’ve never seen a problem with tent cities per se but when I was in NYC a couple years ago, I was eating at an outdoor restaurant and saw a homeless man walk up and start eating out of a trash can! Then, to make it even worse, the waitress just asked us to just look away... but most people have a natural reaction to help others in distress and ever since seeing that I don’t think there’s anything wrong with the government relocating people like that for their own sake! It’s disturbing to think that some homeless people may be chronically homeless because they’re out of their minds and perhaps a more direct and forceful solution is in order to address the homelessness crisis and try and get people back to health and happiness! No one in their right mind wants to live in a tent on the street!
The problem with tent cities is lack of basic sanitation. No toilets, no showers, dishwashing facilities or laundry. Tents are not insulated and therefore don't provide protection from extreme heat of cold.
They do provide a sense of privacy which is important.
yes, good point! I guess what I mean when I say “I’ve never seen a problem with tent cities” is I don’t think the government should make homelessness illegal but I also don’t think too much tolerance or turning a blind eye to destructive behavior is a winning strategy. A healthy society has people who are housed with a community that cares.
Another anecdote on mental health. When I was a kid, around 1960, my closest friends were twins who lived across the street. One day their dad, who was a Cornell professor, disappeared, sent to what was then one of several NY institutions to treat the mentally disturbed, in his case in Willard, NY. He reappeared in six months and went on to a productive career and happy life. The institution he was sent to and all others in New York were later closed on the grounds the insane would be better off living among us. This has turned out to be insane.
There’s still a lot of abuse and profiteering in the mental health industry, and in this age of deinstitutionalization, a risk to society is that people are under-treated or never treated at all. Thanks for sharing and I’m glad the story had a happy ending.
“ Liberals are always debating whether people like Shina should be permitted to live in a tent or forced into services.”
I’ve asked this before but where are the conservatives saying bring back the state hospitals? I haven’t gotten an answer. It seems there is more than enough blame to go around.
Any newspaper comment section about this issue is about 50% blaming it on Reagan, which is probably polarizing it unnecessarily, if your goal is fixing the problem and not just getting thumbs up. (Didn't JFK get the ball rolling on deinstitutionalization? I don't know, but in any case I'm fine blaming it on whoever to get the social incentives right to make people want to get it fixed.)
I've become more swayed to the virtues of involuntary holds in cases of severe mental illness because of Freddie, but in my city of Toronto, they simply rip up the tents and tell people to go to shelters, where there often isn't room (and when there is, it's often a more unpleasant experience than tents, they often require you to abandon pets and most/all personal belongings, and can cause their condition to get worse).
I was talking to someone who told me that he has a homeless friend who is addicted to drugs, and this man deliberately ODs and has him call 911 so he can go to the ER where there's food and a warm bed.
One issue is that for many of these people life outside a secure institutional setting just isn’t possible. Some people are just so mentally ill and/or just so susceptible to substance abuse they simply can’t function in society.
A powerfully illuminating and empathetic piece that serendipitously allows me to discuss with an actor in a play this potential for a character's consciousness that he is having a psychotic episode.
Great stuff as usual, thanks. There is a commercial, I forgot exactly which group sponsors it, but it shows a man crossing the street, encountering himself, and then getting into a fight with himself. It is moving to me, and especially more now because of reading your work on mental illness.
I wonder if there is something to how it seems some really great art is associated with mental illness. Maybe the more frequent and acute requirement at self examination gives someone a greater insight into the human condition. I wouldn't say it's a pre-requisite for good art, or a necessary outcome of a mental illness, but there seems to be a connection there. I know that for me as I get older, self examination, knowing oneself, seems to be the best way to understand the world.
“This may sound weird, but what can happen over time is that you get better at being psychotic.” I think this is an amazing opinion and accurate perspective! Obviously what happened to Amanda is tragic but I constantly hear rather cynical commentary on mental health conditions and that they “can’t be cured”. I love your article because it highlights that while psychosis is serious, especially when it persists as in Amanda’s case, maybe she’s getting a little better because she wasn’t hurt, didn’t hurt anyone else, and asked for help herself. I really think content like yours will help “end the stigma” around mental illnesses like psychosis so that people like Amanda can be treated with the respect and dignity the deserve and hopefully get better! 🫶
Thank you for writing this, Freddie.
"As I’ve mentioned before, the technical term is anosognosia - the inability of the sick to understand that they’re sick. Anosognosia is indeed very common among people with schizophrenia and schizoaffective disorder, but not universal, and while many bipolar patients experience the condition, most estimates I’ve seen suggest that a majority don’t".
My best friend will, most of the time, acknowledge that he has schizophrenia and that he has previously experienced hallucinations and paranoia, but for him, the main voice he hears is an exception this this, and //exploits// the fact that he has diagnosed schizophrenia to hoodwink family, friends and medical staff while continuing to torment him.
Also, in a given conversation, the degree to which he speaks about the owner of this voice as having a concrete embodied existence outside of his head, and to which he speaks about the voice as disembodied and inwardly experienced, can vary (often fairly quickly). It's hard to explain from the outside... but it's like his relationship to metaphor is different to that of most people without schizophrenia. It's definitely important to not think of hallucinations as just "a false overlay on top of empirically real reality" as they are clearly much more complicated than that.
I wonder what, if anything, this implies about AI alignment (partly because I wonder that about everything these days). Yes, sure, there's no ironclad reason to presume that specific aspects of human minds will generalize onto weird superpowered programs. But in my view the most believable AI failure modes sound a lot like how you describe psychotic episodes: thoughts getting lost in themselves; obsessive itches taking over ever-increasingly from rational behavior as real-world feedback fades away; etc.
On the one hand, it's gratifying that minds tend to somewhat recognize when they're misfiring in this way, even as they continue to misfire; i.e. that "meta-rationality" can make sense to human-like minds when the rubber hits the road. On the other, it's worrisome that these tendencies may come and go, in unpredictable waves, and that, at least for humans, we have serious trouble debugging the root cause, even when we solve the specific crisis and offer general diagnoses, tips, resources, etc.
I tend to think this is the sort of failure mode that will characterize near-term worrisome AIs, rather than the issue being like paperclip maximizers. In other words, there seem to be reasons to believe that the most relevant issues will involve "inner misalignment" (learning the wrong heuristics to achieve the right goal), rather than "outer misalignment" (learning, with perfect clarity, the wrong goal). Think of it like how evolution taught us to pursue evolutionary fitness by liking sugar, and being horny, and so forth, because in our ancestral environment these were good and easy strategies to focus on, but now they probably harm our ability to propagate our genes (or at least easily end up getting hacked with activities which evolution would view as psychotic, like non-procreative sex).
In other words, I think the issue won't be that AIs don't learn to care about us -- "human persons" is a very natural abstraction to focus on in their training process -- just as the human species obviously learned to care about our relatives (especially our offspring) despite not having any understanding of DNA until quite recently. But think of all the ways in which parents can fail horribly by caring about their kids way too much (the failure modes I'm thinking of sound a lot like your description of psychosis, but obviously in a much less acute or medicalized way). Or think about how dogs can be optimized to just hijack our impulses to rear cute things, whereas kids have to be optimized to produce kids of their own (or else their genes stop showing up in the human story); so dogs can outcompete kids in this way, precisely as they become completely unfit on their own (think of e.g. how dependent pugs are), hence the fact that there are now more dogs than children in the US.
Here's an I think apropos quote (from https://cebk.substack.com/ [shameless self-promotion]) about how horribly wrong this can go; if the Bing chatbot's alarming hallucinations are any indication of what happens when AIs get unleashed on us, I think this could get bad fast:
You can evaluate whether some advice sounds good within a few seconds; however, you’ll need about a month—i.e. a few million seconds—to actually test out whether it works. Thus, if chatbots are trained by seeking reward, then those that focus on flattering our society’s vapid sensibilities will “evolve” about a million times faster than those that offer us harsh but useful truths (to the extent that reinforcement learning is like natural selection). That’s a huge advantage! If biological evolution had been sped up a million-fold, then dinosaurs would’ve first emerged around 1800, and would’ve gone extinct around 1960. Other forms of machine learning seem even more subject to this extreme social desirability bias: for instance, GPT-style transformer-based attention-only self-supervised prediction models only learn what the text corpus they’re trained on is likely to say about our world, not what’s actually true of it. And because language is already an incredibly effective compression of reality, language programs are likely to stay in control of AI progress.
I don't think language is anywhere near effective at compressing reality - it is just the least worst option we have. Even true masters of language often have a hard time expressing themselves accurately.
Thanks for your continued discussion on mental illness. Regarding involuntary holds, this article discusses pink slips and expanding its usage to severe alcohol and drug addictions. Given the Dayton area's high use of methamphetamines and their influence on neuro functioning with chronic use, it's likely there are co-occurring conditions though I'm not familiar with specifics for methamphetamine use and psychotic disorders (vs depression, anxiety, etc). I'd appreciate your thoughts or if you can point me toward more literature on "pink slips" in general. Thanks!
https://www.daytondailynews.com/news/local/will-expanding-pink-slips-curb-gun-violence/W7ZIFRXJbQP8AlBJq5wm9J/?ecmp=newspaper_email
This makes sense to me. I have never had to deal with mental illness, but it has always seemed that the idea that the mind was a unitary entity was not really that true.
I think people understand this when it comes to urges. Your "rational" mind knows you are on a diet, but part of you still wants a cookie and they fight it out. I tend to think that even your rational mind is subject to conflict. Part of you wants to be on a diet, part of you wants a cookie, and part of you is coming up with ways that you can eat a cookie while still believing you are on a diet.
Years ago, I read a book "Getting to Yes," which was about various negotiation techniques that can make the other side more open to accepting or sticking with you view. I never found it super helpful in negotiating, but a lot of the tricks, e.g. getting them announce a favorable position, have always struck me as a good way to negotiate among myself. I could see someone with a psychotic disorder learning to do the same thing to ensure that, when they are having issues, they still can get themself to get help.
Evaluating insight into their condition when patients try to leave against medical advice can be very interesting. All they really have to say is that they appreciate the doctor thinks they're at risk by leaving but they're willing to take that chance. If they're not organized enough to say something like that, they have to stay.
Although the meaning of anosognosia is specific to clinically-diagnosed psychiatric conditions, I see it as a common and growing trait in modern humans that they are cognitively, emotionally or psychologically dysfunctional but not only don't know it and deny it, but point to others who "think" differently than them as being sick. And many of these people are societal and business leaders. The lack of self-awareness is ubiquitous and growing it seems. Cognitive dissonance results. It starts to feel like all of society is engulfed in some level of psychosis.
And related to self-aware psychosis, I think missing from this analysis is the impact of regular and heavy cannabis use. If ever we can recognize that psychological chemical imbalance contributes to brain dysfunction that contributes to psychological dysfunction, we have the evidence with the evidence of cause from cannabis.
I am starting to question if both, the trend toward more cognitive dissonance and lack of self-awareness AND the trend toward increased cannabis use, are related... and maybe supercharged by screen time on social media.
And then there are those with actual physical mental health challenges competing for treatment attention with those made "sick" by controllable externalizes.
Cannabis isn't the only substance that Amanda Byrnes was using when she began showing signs of severe mental illness. I also question how much of a recent "trend toward increased cannabis use" there is, when it's been very commonly used in the US for decades. A reality that appears to have only assumed crisis proportions in the minds of some observers in the aftermath of legalization efforts in some of the states.
https://people.com/movies/amanda-bynes-first-interview-drug-use-breakdown/
Another substance that Amanda Byrnes was abusing- amphetamines, in the form of Adderall- has in fact undergone a dramatic rise in prescriptions in the past few years: "Prescriptions for a range of drugs to treat ADHD rose 19 percent, on average, between 2018 and 2022, according to a Post review of data from IQVIA, a health-care technology firm. Adderall and its generic versions, however, increased by 35 percent over that time, with the sharpest rise coming during the past two years." https://www.washingtonpost.com/business/2023/03/14/adderall-shortage-telehealth-prescriptions/
So the US is apparently back to the same per capita number of amphetamine prescriptions that were being issued in the 1950s and 1960s.
I can't say how much of this situation might be related to an increase in psychotic behavior in recent years, because I don't have any firm evidence that there has been such an increase. I don't have any data about any increase in "anosognosia" in the US population, either. So unlike yourself, I'm not ready to make any sure assertions about any of this stuff.
> Although the meaning of anosognosia is specific to clinically-diagnosed psychiatric conditions,
It's not; anosognosia applies to neurological and neurodegenerative conditions as well. Iirc it was created to refer to a more specific neurological deficit that affects self-perception due to localized neural damage (cf. visual agnosia and all the other -agnosias) and was widened to apply to conditions like Alzheimer's and anorexia where insight is impaired in a more general sense. A bit of a pet peeve of mine that this occurred since there's a good bit of difference between what's going on with "the man who mistook his wife for a hat" guy and what's going on in schizophrenia but oh well.
Obviously these are very different issues, but a lot of what you describe here lines up with my experiences with disordered eating (both my own and what I have observed in other people who struggle with them). I don't feel I have "healed" from my ED in the way that is often described in popular media, as much as I have learned how to live with and react differently to the "irrational mind" urges, thought patterns, habits and inner monologue that eventually lead to it.
This has been a double-edged sword for me, too -- on the one hand, I have gotten to a point where "learning to live with it" HAS allowed me to live a healthier and more fulfilling life, which feels an awful lot like healing/curing it. At the same time, "learning to live with it" can also look like "learning to hide it," "learning to go through the motions as a 'recovered person' while your mind continues to buzz under the surface," "learning to be just 'healed' enough to escape further treatment/scrutiny but not enough to fully move on," "learning how to game the system," "learning to parrot popular recovery mantras around people who you know scroll that corner of tiktok so you don't have to have a 100th conversation with them about HAES and diet culture" etc. (ok that last one is probably pretty specific to me...). I feel I have been all of these and more, sometimes at once, at different points in time, and while I'm pretty confident I'm headed in the right direction, it's hard to constantly wonder if I'm really on the "right path" or if I'm just doing further self harm. This is even more muddled thanks to modern information overload and access to too many opinions about the right and wrong ways to "be disordered" via the internet and social media.
Again I know these are different illnesses and am definitely not suggesting that my experiences are on the same level as those of someone who deals with psychosis. But this piece really resonated with me and I think this is a very useful framework for discussing mental illness and recovery.
Without presuming to speak for FdB or anyone who experiences psychosis, your description of your eating disorder “recovery” and comparison with his and Bynes’s experiences seems spot on from my pov.
I think it’s uncontroversial this day and age to say that ED and drug addiction are very similar forms of disordered thinking. In my teens and twenties, I burned my life down with heroin and cocaine, racked up felonies etc. I no longer partake of those particular molecules, but I constantly identify the same impulses in my thinking nowadays.
Your description of recovery as “learning to hide it”, go through the motions and heal just enough really resonates with me. I never really got sober, just moved from illegal, full-agonist opioids to partial-agonist prescription drugs for addicts. I learned how to modify dosing schedules to get what i wanted from the drug. When I eventually got off buprenorphine, I found other ways to legally modify my conscious experience that better-aligned with a life not so far on the outskirts of society.
Anyway, thanks for sharing your experience, it’s a helpful way to articulate my own to myself.
I have a delightful neighbour who has Myasthenia Gravis and serious mental health episodes when she sees and hears things. I’m retired as are several other neighbours or are stay at home moms. We watch out for her - but when and she is experiencing an episode, it is indeed difficult to see her being taken to the ER spitting fire at one of us who called for assistance. But when she comes out the other side, we all socialise in the backyard with girl talk and such.
My one experience with bad psychosis (and when I was diagnosed as bipolar) had me very delusional, with hallucinations, and hyper-real violent images playing in my head, which scared the shit out of me. Scared my young daughter too, when I told her I thought I was dying, in tears, and that I was sorry. Immediate access to quality care in these situations is crucial. I was able to see a good psychiatrist that day, because my wife, an MD, called him and said I wanted to go to the hospital. He said to come to his office, where he talked me through the worst of it, reassured me that the drugs would start working soon, and I ended up slowly, slowly recovering over the next couple months like it was a brain injury, without ever being admitted. Saw him once a week for a couple months, then less as time went on. I was definitely conscious and aware, just not at all hopeful that things would turn out well. To me, it felt like a delusional panic attack from hell.