Alexander 2021 Ontology Psychiatric Conditions

29/01/2021 Ontology Of Psychiatric Conditions: Taxometrics - Astral Codex Ten
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Ontology Of Psychiatric Conditions: Taxometrics

Is mental illness a thing? What kind of thing is it?
Jan 28 145 166
[reposted from here, with edits]
I.
Taxometrics is the study of whether psychiatric conditions are categorical or dimensional.
Something is categorical if it neatly, objectively separates into di erent groups. For example,
consider humans and rabbits. If we take a mixed group containing some humans and some
rabbits, and graph them along some variable like weight, it would probably look like this:
There’s one big obvious group around 3 lbs (weight of the average rabbit) and another
around 140 lbs (weight of the average human). Not a lot of subtletly here. If we used some
other graphable variable – height, lifespan, IQ – we’d probably get something similar.
Maybe the biggest rabbit in the world is bigger than the smallest human. That doesn’t mean
they’re not two obvious categories. It just means they’re two obvious categories with a tiny
overlap. It happens.
If we wanted to be clever, we could create a multivariate distance measure that combines

weight, height, lifespan, IQ, and lots of other ways humans and rabbits could di er, into a 0
– 1 variable where 0 is “most rabbity” and 1 is “most humanish”. Probably these scores
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wouldn’t overlap at all – if they did, it would mean there’s some human who’s more like a
rabbit than some rabbit is, which would be pretty surprising. But even if this were true, it
wouldn’t change the fundamental nding that humans and rabbits are pretty di erent. Or
to put it some other way, there’s a fundamental hidden generator producing di erences
between humans and rabbits (in this case, the species di erence).
By contrast, something is dimensional if it’s just a spectrum and there’s no obvious place to
separate it into di erent groups. For example, consider tall people vs. short people. We take
a general cross-section of the population, and graph them by height, and it would probably
look like this:
There’s no clear point where short people stop and tall people begin. Some people are a
little taller than others, and other people taller still, and so on until you’re at Yao Ming.
This doesn’t mean “height doesn’t exist” or “height is just a social construct” or anything
like that. It doesn’t even mean you can’t talk sensibly about “tall people” vs. “short people”.
It just means that Nature doesn’t immediately present you with two distinct categories and
a natural cut-o point in between.
What about well-understood physical diseases? Something like the u is pretty categorical
– either you’re infected with an in uenza virus, or you’re not. But suppose we don’t have any
high-tech u tests available. Instead, we must ask people if they have various u symptoms,
score their answers, and sum up the total. We might end up getting something that looks
like this (not to scale):
The big peak on the le represents the large majority of people, who don’t have us. It’s
sharp but not in nitely sharp, because some people without us will still have a few u
symptoms – maybe they have allergies or something. It’s asymmetrical because there are
more ways to have more u symptoms than average than to have fewer u symptoms than
average (especially if the average number of u symptoms is zero or otherwise very low).
The small hill on the right represents people with the u. It’s much smaller than the le
peak, because people with the u at any given moment are much less common than healthy
people. It’s also much wider, because u can strike at many di erent levels of severity, so
some u patients will barely have any more u symptoms than the average person, and
others will be very sick.
Something like hypertension is more dimensional. A graph of how many people have what
blood pressures might look like this:
This doesn’t obviously separate into two groups, “hypertensive” and “non-hypertensive”.
We just arbitrarily decide on a cuto (in the case of hypertension, 130 mm Hg systolic) and
call the people above it “hypertensive” and the people below it “not-hypertensive”.
In the u case, we can ask the additional question “This person has few u symptoms, but
is it possible that’s deceptive and they actually do have the u?” In the case of hypertension,
you cannot ask “This person has a low blood pressure, but is it possible that’s deceptive and
they actually have hypertension?” It just doesn’t make sense! In the u case, we’re using the
thing we measure as a proxy for some underlying fundamental di erence (whether they’re
infected with an in uenza virus or not). In the hypertension case, we’re just grading the
level of what we’re measuring.
So taxometrics is the study of whether psychiatric disorders work more like the u, or more
like hypertension.
For example, take generalized anxiety disorder. One possibility is that some people have
some weird brain quirk called “generalized anxiety disorder” and the rest of us don’t, and
we measure anxiety level to try to identify the people with that particular brain quirk.
Another possibility is that people just have di erent anxiety levels, and for some people
that anxiety level is so high that it bothers them, and we call that “generalized anxiety
disorder”.
If we wanted to determine which one of those was true, we might try giving people a bunch
of questions about how anxious they are, then graphing the answers on a plot like the one
above. We already have good tests for how anxious people are – things like the GAD-7. So
we can just graph GAD-7 scores and then we…
…in fact, this doesn’t work. Let’s look at the u graph above again.
I admitted above that it wasn’t to scale. If we made it more to scale, it might look like this
(seen separately and color-coded on the le , combined on the right):
Because the “has u” category is so small and so spread-out, it’s actually really hard to
notice the tiny secondary bump representing its existence as a separate ontological
category. If we tried to just eyeball the distribution of answers on a u-symptom-
questionnaire, we would end up pretty doubtful that the u was a real thing. Add in the
inevitable measurement error, and this just isn’t going to be helpful.
So actual taxometricians use more complicated statistical methods. Theodore Beauchaine

describes three of them here, of which I’ll try to very brie y explain one of the simplest,
MAXCOV.
Suppose a category is real and involves at least three correlated traits. For example, human
vs. rabbit involves weight, lifespan, and IQ; healthy vs. u involves cough, fever, and muscle
pain. Pick one trait – let’s say cough. If the u is a real category, then as we go from lowest-
cough-level to highest-cough-level, the people we’re looking at should gradually go from

mostly-not-having-the- u to 50-50 to mostly-having-the- u.
In a a group of people who are 100% healthy, 0% u, fever and muscle pain should correlate
at some level. In a group of people who are 0% healthy, 100% u, fever and muscle pain
should correlate at some other level. In a group that’s 50-50, the correlation should be
higher than either of these! That’s because level of fever gives you a clue to who has the u,
which in turn gives you a clue about who has muscle pain. In both the 100-0 and 0-100
groups, level of fever doesn’t tell you anything about who has the u (everyone has the same
u status), so the existence of u doesn’t give you any useful information. That means that if
a categorical di erence exists, you should expect the correlation between fever and muscle
pain to peak at the level of cough that most e ectively divides u patients from non- u
patients.
This is Figure 3 from the Beauchaine paper linked above. The rst graph depicts an
objectively-existing-categorical depression that works like species or in uenza. As you
increase the level of one depression symptom (unintended weight loss), the correlation
between two other depression symptoms (early morning awakening and psychomotor
retardation) gradually goes up, peaks at 14, and then starts going down. This suggests that
in this case, depression is a real category, like the u, and the best cuto to separate
depressed from non-depressed people is at 14 of whatever this variable is.
The second graph depicts a dimensional depression that works like height or wealth. As
you increase the level of one depression symptom (insomnia), the correlation between other
depression symptoms (sadness and crying) stays about the same. This seems a bit o to me –
sadness and crying seem like a uniquely bad pair of symptoms to theorize are correlated
mostly because of the construct of depression – but whatever, it’s just an example.
Clear as mud? Don’t worry, this isn’t really what most taxometricians use. They use things
that are much more complicated. Any statisticians reading this might enjoy this paper on
using the comparison curve t index in taxometric analyses; no guarantees about anyone
else.
II.
In the Brief Taxometrics Primer I’ve been trying to loosely follow in this post, Beauchaine
strongly suggests, though doesn’t say outright, that most psychiatric disorders are
dimensional, like height and wealth. But a few may be objective distinct categories,
especially schizophrenia, narcissistic personality, and endogenous depression (a subtype of
depression that happens for no reason, as opposed to the kind of depression you get when
something bad happens). This is a completely reasonable set of ndings which match my
intuition and the intuitions of most other psychiatrists.
But the past two decades of research have treated it poorly. The most up-to-date and
comprehensive meta-analysis of taxometric research I can nd is Haslam, McGrath, and
Kuppens from 2020 . It strongly agrees with (my read of) Beauchaine that most psychiatric
conditions are dimensional like height or wealth. It is able to nd only hints of exceptions,
nothing that it can con dently state is a true category. But its list of exceptions is
completely di erent from Beauchaine’s, and much less sensible. It points to pedophilia,
addictions (including gambling addiction!), autism, and intermittent explosive disorder as
the most likely candidates for taxonicity (their fancy word for being a true categorical
distinction like species or u).
I’ll grant them pedophilia – it really does seem like people either are or aren’t pedophiles
and there’s something weird and speci c going on there.
Addictions (they speci cally name alcoholism, nicotine addiction, and pathological
gambling) are more surprising – doesn’t alcoholism progress pretty gradually from
teetotalers to social drinkers to heavy drinkers to raging alcoholics? Doesn’t smoking go
from the occasional smoker to pack-a-day smokers to extremely heavy smokers? I haven’t
hunted down all their individual studies, but I suspect this is a sort of artifact of how people
respond to their addictions. For example, people who have lots of problems with tobacco
either successfully quit and become nonsmokers, or don’t quit and become heavy smokers.
So there might be an arti cial divide where the only people who smoke are the people who
do it socially and enjoy it and feel no reason to quit, and the people who are so addicted
they can’t possibly quit.
Autism is such an annoying thing to have on this list – just when everyone nally agreed
there was an “autism spectrum” and no clear di erence between neurotypical-people-with-
some-autistic-traits and high-functioning-autistics, along comes this meta-analysis to say
nope, it’s a taxon, neurotypicals and autistics are two clear objectively separate categories. I
did hunt down the studies here and they actually seemed pretty good. But none of these
results are strong enough to be more than suggestive, so I am going to keep believing in an
autism spectrum until more research comes in.
And intermittent explosive disorder! This is the fake disorder we made up so that we had
something to diagnose angry people with! I don’t think anyone thought this one was real,
not even the psychiatrists who invented it and stuck it in the DSM! But here come the
taxometricians, saying that schizophrenia and bipolar and whatever are mere dimensional
variation, but IED (yes, that’s really the acronym) is an honest-to-goodness crisply-de ned
category based on objective reality? What gives?
And look what isn’t on here – schizophrenia, which is just a really obvious separate taxon.
You know, the condition where sometimes between ages 18 and 25 for men and ages 25 to
35 or so for women, over the course of a few weeks, seemingly normal people start getting
extreme hallucinations and eventually devolve into a state where they o en can’t live a
normal life or even speak meaningful sentences? The taxometricians are saying ah,
whatever, it happens to all of us, they’re just the people who it happens to more than
average? Is that really what they’re saying? I think they may have bungled this one, maybe
by over-focusing on studies of negative symptoms, or of psychosis more generally, but I
haven’t looked into it enough to be sure.
Overall this is just a really enraging meta-analysis, and even though their methods look
good and they did a lot of work to double-check their results, I have trouble trusting them.
To their credit, they are pretty careful about what claims they make, and only say that the
data is suggestive of most of their categoricity claims.
Maybe instead of focusing on these few tenuous exceptions, we should focus on the
headline result: 75% of ndings were “unambiguously non-taxonic”, 17% were
“unambiguously taxonic”, and 8% were “ambiguous”. In other words, the eld as a whole
pretty strongly suggests that most psychiatric disorders are just the tail end of normal
variation, like “tall person” or “rich person”, and not a separate category like “rabbit” or
“has the u”. Among the conditions that were very strongly found to be dimensional only
were depression, anxiety, and ADHD.
In more depth:
This is a forest plot of CCFI, the more complicated taxometry statistic I linked before.
CCFI below 0.5 suggests dimensional variation like height or wealth; above 0.5 suggests
true categories like species or having-the- u. This plot is using much broader categories
than the individual conditions I mentioned before, but we can see that eating disorders (like
anorexia), childhood disorders (like autism), substance use (like alcoholism), and a bunch of
grab bag categories (including things like dementia) are most likely to look taxonic.
A few other things stand out here. Just for fun, the authors included some normal
personality traits and psychological variables, like “religious fundamentalism” and “interest
in science”. I think (though they don’t say so explicitly) that Big Five traits like extraversion
and so on are also in there. They predictably nd low CCFI for these, meaning they’re just
dimensional normal variation. These are honestly around the same CCFI as anxiety and
mood disorders, meaning that “depression” behaves in as trait-like a way as “interest in

science”, and vice versa. If you weren’t planning on coming up with some separate category
of “science-lovers” and demanding everyone classify themselves as in it or out of it, you
probably shouldn’t do the same with depression.
They also have a category called “gender”. They say they included measures like
“femininity” and “sex-stereotyped activities” in there – I can’t nd more speci cs. It has a
CCFI of 0.42 with con dence interval including 0.5, so looks slightly more dimensional, but
can’t quite rule out it being slightly more categorical. If anyone ever demands you have an
opinion on the question “is binary gender real?”, I think the most scienti cally-supported
answer would be “it has a Comparative Curve Fit Index of 0.42 plus or minus 0.1, which
means it trends towards dimensionality but taxonicity cannot be ruled out”. There’s also a
“sexuality” category on here, but it’s such a grab bag of di erent things (sexual orientation,
how promiscuous you are, etc) that I’m not sure you can get much out of it; look at the
individual studies if you want to know more.
III.
Does this mean that, contra all those public awareness campaigns, “depression is just
normal sadness” or whatever?
I’m not sure clinical depression is even kind of the same sort of thing as sadness. Lots of
aspects of depression - like its tendency to occur in episodes lasting on average six months
to a year - don’t seem like jacked-up aspects of normal sadness. So maybe this a bad
example. But we can probably come up with equally awkward questions about other
conditions. Is Generalized Anxiety Disorder just normal anxiety? Is ADHD just normal
absent-mindedness?
Not necessarily normal. As the old saying goes, quantity has a quality all its own. Just
because something is on a continuum with something else, doesn’t mean it has to be close
to it.
Suppose you make the US median income of $36,000/year. You live in an average American
town where you see people of various social strata. Your doctor makes $200,000/year and
drives a Tesla. Your sister is a single mother making $20,000/year, and needs food stamps to
make ends meet. You probably think you have a good sense of class distinctions.
What about Je Bezos? Is Bezos’ fortune “just normal wealth”?
Taxometrically: yes. Je Bezos falls on the same continuum as everyone else. You can add
one dollar to your own net worth, and keep doing that, and eventually end up at Je Bezos’
https://astralcodexten.substack.com/p/ontology-of-psychiatric-conditions?token=eyJ1c2VyX2lkIjoxNTEwNzA0LCJwb3N0X2lkIjozMTk0OTU4OSwiXyI6Ik… 10/14
net worth. At every point in between - a few hundred thousand, a few million, a few tens of
millions - there will be some people at that point. There’s no clear distinction into two
disjoint groups, where you’re in one and Je Bezos is in the other.
Practically: no. Practically, Je Bezos might as well be a di erent species. If your idea of
wealth is a doctor who makes $200,000 a year, you’re totally unprepared to think about Je
Bezos. Your whole economic world between the poor single mother and the rich doctor
occupies one order of magnitude; Je Bezos is ve orders of magnitude beyond it.
In Nassim Taleb’s language, Je Bezos lives in Extremistan. If you’re expecting a normal

distribution, Bezos is way outside of it and looks like a di erent species. But really he’s just
at the tail end of a distribution with much longer tails than you expected.
If this is true, I think it's fair to think of severe ADHD as having the same relationship to
normal absent-mindedness that Je Bezos has a to a guy making a little above median
income. They’re the same sort of thing on the same distribution. But one is so much further
out than our normal vocabulary for talking about these kinds of di erences that it's okay to
have a di erent word for it and di erent intuitions around it.
IV.
If most mental disorders are dimensional variation rather than taxa, that kind of makes the
DSM look pretty silly, doesn’t it?
Remember, the DSM is fundamentally a diagnostic guide. It’s a list of criteria to determine
who has eg depression. To oversimplify just a little, if a patient has ve or more of their
depression criteria, then they “really have” depression, and a psychiatrist should diagnose
them. If they only meet four or fewer, they don’t have depression, and should not get the
diagnosis. All of this is predicated on the idea that there’s a speci c thing called depression
that you either do or don’t have.
Dimensional variation doesn’t work that way. Let’s return to our wealth analogy. Imagine a
manual which let you diagnose someone as “rich” only if they meet at least three of the
following criteria:
1. Owns ve or more cars

2. Has a house in a gated community
3. Has an income of $1,000,000 a year or above
4. Takes rst-class ights at least three times a year
5. Engages in rich-person activities (horseback-riding, gol ng, reading the New Yorker) at
least twice a month
…and then every few years economists get into huge ghts about whether maybe we should
change this and say you have to own six or more cars, or whether there should be an
exemption for people who own fewer cars but do have a private jet, and they all take it really
really seriously.
The problem isn’t that the criteria are wrong. All of these are perfectly reasonable
characteristics to correlate with richness. The problem is that your project of dividing the
world into “rich” and “not rich” is fundamentally not a scienti c one, and is more likely to
confuse than to enlighten. Someone with an income of $999,999 isn’t interestingly di erent
from someone with an income of $1,000,001; owning four cars blends seamlessly into
owning ve.
This isn’t to say you never want to do something like this. Suppose Bernie Sanders wants to
increase taxes on the rich, but not on everyone else. He needs some regulation about who
the increased taxes hit, and maybe something like this checklist (or more realistically just
the income cuto at $1,000,000) is the way to go. It’s ne if he wants to set something up
like that – as long as economists don’t look at his division of people into two bins and
mistake it for the discovery of an underlying cosmic secret that there are two types of
people, rich and non-rich, separated by the $1,000,000-a-year mark.
Are psychiatrists mistaking moderately useful bins for underlying cosmic secrets? It’s hard
for me to tell exactly how many people make this mistake; the people who understand
what’s going on and are just using the categories as rules-of-thumb tend to sound a lot like
the people who don’t. My guess is most professionals, and an overwhelming majority of
laymen, are actually confused on this point, and this messes them up in a lot of ways.
An economist or sociologist looking for the causes of wealth or poverty understands that
they’re doing a pretty complicated thing. In the complex system that is human economic
behavior, they will probably nd that all sorts of factors like upbringing, education,
genetics, health, discrimination, and luck interact to determine how much money you have.
On the other hand, a microbiologist looking for the cause of the u will be hoping to nd a
single speci c thing – one virus that all u patients have and all healthy people don’t. I
think a lot of people still want psychiatry to deliver the single speci c thing. It’s not going
to be able to do that. If you hold out hope, you’ll either end up overmedicalizing everything,
or you’ll get disillusioned and radicalized and start saying all psychiatry is fake. I think
either would be a mistake.
In my practice, I’ve moved away from asking questions like “does this patient really have
ADHD”? Those kinds of questions make me feel like I’m trying to decode their symptoms
to uncover some secret variable that could be either 0 or 1. But there is no such variable.
Instead, I ask “how much trouble does this person have with paying attention?”. This is
usually pretty easy to gure out; the patient will just tell me if I ask!
Likewise, I’ve moved away from thought processes like “If this person has ADHD, they
genuinely need a stimulant; if not, they’re just faking”. Instead, I try to think of how much
the patient’s symptoms are disabling them, whether a stimulant would relieve some of those
symptoms, how likely the symptoms are to go away without an stimulant, and, based on all
this, whether the bene ts of a stimulant outweigh the risks.
(this has another implication: stimulants shouldn’t be thought of as magic bullets that
“cure” “ADHD” by xing the underlying cause, in the same way that Tami u cures the u
by blocking u viruses. They should be thought of as things that a ect the underlying stew
of variables that cause ADHD in some helpful way. By comparison, giving someone a
college scholarship might help them become richer, but it’s not “curing” “the” “cause” of
“poverty” in a way that ips them from a “not rich” to a “rich” status.)
Also, this is why I don’t like the pressure to use person-centered-language (eg instead of
“autistic person”, you should say “person with autism”). This sends exactly the wrong signal.
If autism is dimensional, we should think of it the same way we do height and wealth – and
we say “tall person” and “rich person”. Saying “person with Height” or “Person with
Richness” is strongly suggestive of “person with the u” – it implies a binary class that you
either fall into, or don’t. But that’s the opposite of what most research suggests, and the
opposite of the thought process that will help you think about these conditions sensibly.
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29/01/2021 Ontology Of Psychiatric Conditions: Taxometrics - Astral Codex Ten

Ontology Of Psychiatric Conditions: Taxometrics

Taxometrics is the study of whether psychiatric conditions are categorical or dimensional.

If we wanted to be clever, we could create a multivariate distance measure that combines

So actual taxometricians use more complicated statistical methods. Theodore Beauchaine

cough-level to highest-cough-level, the people we’re looking at should gradually go from

mood disorders, meaning that “depression” behaves in as trait-like a way as “interest in

What about Je Bezos? Is Bezos’ fortune “just normal wealth”?

In Nassim Taleb’s language, Je Bezos lives in Extremistan. If you’re expecting a normal

1. Owns ve or more cars

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