migraine

The economic impact of chronic illness

pnrj core principles, ethics, inequality, market failure, personal, public policy , , , , , , , , , ,

Mar 27 JDN 2459666

This topic is quite personal for me, as someone who has suffered from chronic migraines since adolescence. Some days, weeks, and months are better than others. This past month has been the worst I have felt since 2019, when we moved into an apartment that turned out to be full of mold. This time, there is no clear trigger—which also means no easy escape.

The economic impact of chronic illness is enormous. 90% of US healthcare spending is on people with chronic illnesses, including mental illnesses—and the US has the most expensive healthcare system in the world by almost any measure. Over 55% of adult Medicaid beneficiaries have two or more chronic illnesses.

The total annual cost of all chronic illnesses is hard to estimate, but it’s definitely somewhere in the trillions of dollars per year. The World Economic Forum estimated that number at $47 trillion over the next 20 years, which I actually consider conservative. I think this is counting how much we actually spend and some notion of lost productivity, as well as the (fraught) concept of the value of a statistical life—but I don’t think it’s putting a sensible value on the actual suffering. This will effectively undervalue poor people who are suffering severely but can’t get treated—because they spend little and can’t put a large dollar value on their lives. In the US, where the data is the best, the total cost of chronic illness comes to nearly $4 trillion per year—20% of GDP. If other countries are as bad or worse (and I don’t see why they would be better), then we’re looking at something like $17 trillion in real cost every single year; so over the next 20 years that’s not $47 trillion—it’s over $340 trillion.

Over half of US adults have at least one of the following, and over a quarter have two or more: arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, or kidney disease. (Actually the former very nearly implies the latter, unless chronic conditions somehow prevented one another. Two statistically independent events with 50% probability will jointly occur 25% of the time: Flip two coins.)

Unsurprisingly, age is positively correlated with chronic illness. Income is negatively correlated, both because chronic illnesses reduce job opportunities and because poorer people have more trouble getting good treatment. I am the exception that proves the rule, the upper-middle-class professional with both a PhD and a severe chronic illness.

There seems to be a common perception that chronic illness is largely a “First World problem”, but in fact chronic illnesses are more common—and much less poorly treated—in countries with low and moderate levels of development than they are in the most highly-developed countries. Over 75% of all deaths by non-communicable disease are in low- and middle-income countries. The proportion of deaths that is caused by non-communicable diseases is higher in high-income countries—but that’s because other diseases have been basically eradicated from high-income countries. People in rich countries actually suffer less from chronic illness than people in poor countries (on average).

It’s always a good idea to be careful of the distinction between incidence and prevalence, but with chronic illness this is particularly important, because (almost by definition) chronic illnesses last longer and so can have very high prevalence even with low incidence. Indeed, the odds of someone getting their first migraine (incidence) are low precisely because the odds of being someone who gets migraines (prevalence) is so high.

Quite high in fact: About 10% of men and 20% of women get migraines at least occasionally—though only about 8% of these (so 1% of men and 2% of women) get chronic migraines. Indeed, because ti is both common and can be quite severe, migraine is the second-most disabling condition worldwide as measured by years lived with disability (YLD), after low back pain. Neurologists are particularly likely to get migraines; the paper I linked speculates that they are better at realizing they have migraines, but I think we also need to consider the possibility of self-selection bias where people with migraines may be more likely to become neurologists. (I considered it, and it seems at least as good a reason as becoming a dentist because your name is Denise.)

If you order causes by the number of disability-adjusted life years (DALYs) they cost, chronic conditions rank quite high: while cardiovascular disease and cancer rate by far the highest, diabetes and kidney disease, mental disorders, neurological disorders, and musculoskeletal disorders all rate higher than malaria, HIV, or any other infection except respiratory infections (read: tuberculosis, influenza, and, once these charts are updated for the next few years, COVID). Note also that at the very bottom is “conflict and terrorism”—that’s all organized violence in the world—and natural disasters. Mental disorders alone cost the world 20 times as many DALYs as all conflict and terrorism combined.

Love the disabled, hate the disability

pnrj core principles, ethics, heuristics and biases, personal , , , , , , , ,

Aug 1 JDN 2459428

There is a common phrase Christians like to say: “Love the sinner, hate the sin.” This seems to be honored more in the breach than the observance, and many of the things that most Christians consider “sins” are utterly harmless or even good; but the principle is actually quite sound. You can disagree with someone or even believe that what they are doing is wrong while still respecting them as a human being. Indeed, my attitude toward religion is very much “Love the believer, hate the belief.” (Though somehow they don’t seem to like that one so much….)

Yet while ethically this is often the correct attitude, psychologically it can be very difficult for people to maintain. The Halo Effect is a powerful bias, and most people recoil instinctively from saying anything good about someone bad or anything bad about someone good. This can make it uncomfortable to simply state objective facts like “Hitler was a charismatic leader” or “Stalin was a competent administrator”—how dare you say something good about someone so evil? Yet in fact Hitler and Stalin could never have accomplished so much evil if they didn’t have these positive attributes—if we want to understand how such atrocities can occur and prevent them in the future, we need to recognize that evil people can also be charismatic and competent.

Halo Effect also makes it difficult for people to understand the complexities of historical figures who have facets of both great good and great evil: Thomas Jefferson led the charge on inventing modern democracy—but he also owned and raped slaves. Lately it seems like the left wants to deny the former and the right wants to deny the latter; but both are historical truths that important to know.

Halo Effect is the best explanation I have for why so many disability activists want to deny that disabilities are inherently bad. They can’t keep in their head the basic principle of “Love the disabled, hate the disability.”

There is a large community of deaf people who say that being deaf isn’t bad. There are even some blind people who say that being blind isn’t bad—though they’re considerably rarer.

Is music valuable? Is art valuable? Is the world better off because Mozart’s symphonies and the Mona Lisa exist? Yes. It follows that being unable to experience these things is bad. Therefore blindness and deafness are bad. QED.


No human being is made better of by not being able to do something. More capability is better than less capability. More freedom is better than less freedom. Less pain is better than more pain.

(Actually there are a few exceptions to “less pain is better than more pain”: People with CIPA are incapable of feeling pain even when injured, which is very dangerous.)

From this, it follows immediately that disabilities are bad and we should be trying to fix them.

And frankly this seems so utterly obvious to me that it’s hard for me to understand why anyone could possibly disagree. Maybe people who are blind or deaf simply don’t know what they’re missing? Even that isn’t a complete explanation, because I don’t know what it would be like to experience four dimensions or see ultraviolet—yet I still think that I’d be better off if I could. If there were people who had these experiences telling me how great they are, I’d be certain of it.

Don’t get me wrong: A lot of ableist discrimination does exist, and much of it seems to come from the same psychological attitude: Since being disabled is bad, they think that disabled people must be bad and we shouldn’t do anything to make them better off because they are bad. Stated outright this sounds ludicrous; but most people who think this way don’t consciously reflect on it. They just have a general sense of badness related to disability which then rubs off on their attitudes toward disabled people as well.

Yet it makes hardly any more sense to go the other way: Disabled people are human beings of value, they are good; therefore their disabilities are good? Therefore this thing that harms and limits them is good?

It’s certainly true that most disabilities would be more manageable with better accommodations, and many of those accommodations would be astonishingly easy and cheap to implement. It’s terrible that we often fail to do this. Yet the fact remains: The best-case scenario would be not needing accommodations because we can simply cure the disability.

It never ceases to baffle me that disability activists will say things like this:

“A wheelchair user isn’t disabled because of the impairment that interferes with her ability to walk, but because society refuses to make spaces wheelchair-accessible.”

No, the problem is pretty clearly the fact that she can’t walk. There are various ways that we could make society more accessible to people in wheelchairs—and we should do those things—but there are inherently certain things you simply cannot do if you can’t walk, and that has nothing to do with anything society does. You would be better off if society were more accommodating, but you’d be better off still if you could simply walk again.

Perhaps my perspective on this is skewed, because my major disability—chronic migraine—involves agonizing, debilitating chronic pain. Perhaps people whose disabilities don’t cause them continual agony can convince themselves that there’s nothing wrong with them. But it seems pretty obvious to me that I would be better off without migraines.

Indeed, it’s utterly alien to my experience to hear people say things like this: “We’re not suffering. We’re just living our lives in a different way.” I’m definitely suffering, thank you very much. Maybe not everyone with disabilities is suffering—but a lot of us definitely are. Every single day I have to maintain specific habits and avoid triggers, and I still get severe headaches twice a week. I had a particularly nasty one just this morning.

There are some more ambiguous cases, to be sure: Neurodivergences like autism and ADHD that exist on a spectrum, where the most extreme forms are utterly debilitating but the mildest forms are simply ordinary variation. It can be difficult to draw the line at when we should be willing to treat and when we shouldn’t; but this isn’t fundamentally different from the sort of question psychiatrists deal with all the time, regarding the difference between normal sadness and nervousness versus pathological depression and anxiety disorders.

Of course there is natural variation in almost all human traits, and one can have less of something good without it being pathological. Some things we call disabilities could just be considered below-average capabilities within ordinary variation. Yet even then, if we could make everyone healthier, stronger, faster, tougher, and smarter than they currently are, I have trouble seeing why we wouldn’t want to do that. I don’t even see any particular reason to think that the current human average—or even the current human maximum—is in any way optimal. Better is better. If we have the option to become transhuman gods, why wouldn’t we?

Another way to see this is to think about how utterly insane it would be to actively try to create disabilities. If there’s nothing wrong with being deaf, why not intentionally deafen yourself? If being bound to a wheelchair is not a bad thing, why not go get your legs paralyzed? If being blind isn’t so bad, why not stare into a welding torth? In these cases you’d even have consented—which is absolutely not the case for an innate disability. I never consented to these migraines and never would have.

I respect individual autonomy, so I would never force someone to get treatment for their disability. I even recognize that society can pressure people to do things they wouldn’t want to, and so maybe occasionally people really are better off being unable to do something so that nobody can pressure them into it. But it still seems utterly baffling to me that there are people who argue that we’d be better off not even having the option to make our bodies work better.

I think this is actually a major reason why disability activism hasn’t been more effective; the most vocal activists are the ones saying ridiculous things like “the problem isn’t my disability, it’s your lack of accommodations” or “there’s nothing wrong with being unable to hear”. If there is anything you’d be able to do if your disability didn’t exist that you can’t do even with accommodations, that isn’t true—and there basically always is.

Motivation under trauma

pnrj current events, ethics, personal, science and academia , , , , , , , , , ,

May 3 JDN 2458971

Whenever I ask someone how they are doing lately, I get the same answer: “Pretty good, under the circumstances.” There seems to be a general sense that—at least among the sort of people I interact with regularly—that our own lives are still proceeding more or less normally, as we watch in horror the crises surrounding us. Nothing in particular is going wrong for us specifically. Everything is fine, except for the things that are wrong for everyone everywhere.

One thing that seems to be particularly difficult for a lot of us is the sense that we suddenly have so much time on our hands, but can’t find the motivation to actually use this time productively. So many hours of our lives were wasted on commuting or going to meetings or attending various events we didn’t really care much about but didn’t want to feel like we had missed out on. But now that we have these hours back, we can’t find the strength to use them well.

This is because we are now, as an entire society, experiencing a form of trauma. One of the most common long-term effects of post-traumatic stress disorder is a loss of motivation. Faced with suffering we have no power to control, we are made helpless by this traumatic experience; and this makes us learn to feel helpless in other domains.

There is a classic experiment about learned helplessness; like many old classic experiments, its ethics are a bit questionable. Though unlike many such experiments (glares at Zimbardo), its experimental rigor was ironclad. Dogs were divided into three groups. Group 1 was just a control, where the dogs were tied up for a while and then let go. Dogs in groups 2 and 3 were placed into a crate with a floor that could shock them. Dogs in group 2 had a lever they could press to make the shocks stop. Dogs in group 3 did not. (They actually gave the group 2 dogs control over the group 3 dogs to make the shock times exactly equal; but the dogs had no way to know that, so as far as they knew the shocks ended at random.)

Later, dogs from both groups were put into another crate, where they no longer had a lever to press, but they could jump over a barrier to a different part of the crate where the shocks wouldn’t happen. The dogs from group 2, who had previously had some control over their own pain, were able to quickly learn to do this. The dogs from group 3, who had previously felt pain apparently at random, had a very hard time learning this, if they could ever learn it at all. They’d just lay there and suffer the shocks, unable to bring themselves to even try to leap the barrier.

The group 3 dogs just knew there was nothing they could do. During their previous experience of the trauma, all their actions were futile, and so in this new trauma they were certain that their actions would remain futile. When nothing you do matters, the only sensible thing to do is nothing; and so they did. They had learned to be helpless.

I think for me, chronic migraines were my first crate. For years of my life there was basically nothing I could do to prevent myself from getting migraines—honestly the thing that would have helped most would have been to stop getting up for high school that started at 7:40 AM every morning. Eventually I found a good neurologist and got various treatments, as well as learned about various triggers and found ways to avoid most of them. (Let me know if you ever figure out a way to avoid stress.) My migraines are now far less frequent than they were when I was a teenager, though they are still far more frequent than I would prefer.

Yet, I think I still have not fully unlearned the helplessness that migraines taught me. Every time I get another migraine despite all the medications I’ve taken and all the triggers I’ve religiously avoided, this suffering beyond my control acts as another reminder of the ultimate caprice of the universe. There are so many things in our lives that we cannot control that it can be easy to lose sight of what we can.

This pandemic is a trauma that the whole world is now going through. And perhaps that unity of experience will ultimately save us—it will make us see the world and each other a little differently than we did before.

There are a few things you can do to reduce your own risk of getting or spreading the COVID-19 infection, like washing your hands regularly, avoiding social contact, and wearing masks when you go outside. And of course you should do these things. But the truth really is that there is very little any one of us can do to stop this global pandemic. We can watch the numbers tick up almost in real-time—as of this writing, 1 million cases and over 50,000 deaths in the US, 3 million cases and over 200,000 deaths worldwide—but there is very little we can do to change those numbers.

Sometimes we really are helpless. The challenge we face is not to let this genuine helplessness bleed over and make us feel helpless about other aspects of our lives. We are currently sitting in a crate with no lever, where the shocks will begin and end beyond our control. But the day will come when we are delivered to a new crate, and given the chance to leap over a barrier; we must find the strength to take that leap.

For now, I think we can forgive ourselves for getting less done than we might have hoped. We’re still not really out of that first crate.

Do I want to stay in academia?

pnrj personal, science and academia , , , , , , , , , ,

Apr 5 JDN 2458945

This is a very personal post. You’re not going to learn any new content today; but this is what I needed to write about right now.

I am now nearly finished with my dissertation. It only requires three papers (which, quite honestly, have very little to do with one another). I just got my second paper signed off on, and my third is far enough along that I can probably finish it in a couple of months.

I feel like I ought to be more excited than I am. Mostly what I feel right now is dread.

Yes, some of that dread is the ongoing pandemic—though I am pleased to report that the global number of cases of COVID-19 has substantially undershot the estimates I made last week, suggesting that at least most places are getting the virus under control. The number of cases and number of deaths has about doubled in the past week, which is a lot better than doubling every two days as it was at the start of the pandemic. And that’s all I want to say about COVID-19 today, because I’m sure you’re as tired of the wall-to-wall coverage of it as I am.

But most of the dread is about my own life, mainly my career path. More and more I’m finding that the world of academic research just isn’t working for me. The actual research part I like, and I’m good at it; but then it comes time to publish, and the journal system is so fundamentally broken, so agonizingly capricious, and has such ludicrous power over the careers of young academics that I’m really not sure I want to stay in this line of work. I honestly think I’d prefer they just flip a coin when you graduate and you get a tenure-track job if you get heads. Or maybe journals could roll a 20-sided die for each paper submitted and publish the papers that get 19 or 20. At least then the powers that be couldn’t convince themselves that their totally arbitrary and fundamentally unjust selection process was actually based on deep wisdom and selecting the most qualified individuals.

In any case I’m fairly sure at this point that I won’t have any publications in peer-reviewed journals by the time I graduate. It’s possible I still could—I actually still have decent odds with two co-authored papers, at least—but I certainly do not expect to. My chances of getting into a top journal at this point are basically negligible.

If I weren’t trying to get into academia, that fact would be basically irrelevant. I think most private businesses and government agencies are fairly well aware of the deep defects in the academic publishing system, and really don’t put a whole lot of weight on its conclusions. But in academia, publication is everything. Specifically, publication in top journals.

For this reason, I am now seriously considering leaving academia once I graduate. The more contact I have with the academic publishing system the more miserable I feel. The idea of spending another six or seven years desperately trying to get published in order to satisfy a tenure committee sounds about as appealing right now as having my fingernails pulled out one by one.

This would mean giving up on a lifelong dream. It would mean wondering why I even bothered with the PhD, when the first MA—let alone the second—would probably have been enough for most government or industry careers. And it means trying to fit myself into a new mold that I may find I hate just as much for different reasons: A steady 9-to-5 work schedule is a lot harder to sustain when waking up before 10 AM consistently gives you migraines. (In theory, there are ways to get special accommodations for that sort of thing; in practice, I’m sure most employers would drag their feet as much as possible, because in our culture a phase-delayed circadian rhythm is tantamount to being lazy and therefore worthless.)

Or perhaps I should aim for a lecturer position, perhaps at a smaller college, that isn’t so obsessed with research publication. This would still dull my dream, but would not require abandoning it entirely.

I was asked a few months ago what my dream job is, and I realized: It is almost what I actually have. It is so tantalizingly close to what I am actually headed for that it is painful. The reality is a twisted mirror of the dream.

I want to teach. I want to do research. I want to write. And I get to do those things, yes. But I want to them without the layers of bureaucracy, without the tiers of arbitrary social status called ‘prestige’, without the hyper-competitive and capricious system of journal publication. Honestly I want to do them without grading or dealing with publishers at all—though I can at least understand why some mechanisms for evaluating student progress and disseminating research are useful, even if our current systems for doing so are fundamentally defective.

It feels as though I have been running a marathon, but was only given a vague notion of the route beforehand. There were a series of flags to follow: This way to the bachelor’s, this way to the master’s, that way to advance to candidacy. Then when I come to the last set of flags, the finish line now visible at the horizon, I see that there is an obstacle course placed in my way, with obstacles I was never warned about, much less trained for. A whole new set of skills, maybe even a whole different personality, is necessary to surpass these new obstacles, and I feel utterly unprepared.

It is as if the last mile of my marathon must bedone on horseback, and I’ve never learned to ride a horse—no one ever told me I would need to ride a horse. (Or maybe they did and I didn’t listen?) And now every time I try to mount one, I fall off immediately; and the injuries I sustain seem to be worse every time. The bruises I thought would heal only get worse. The horses I must ride are research journals, and the injuries when I fall are psychological—but no less real, all too real. With each attempt I keep hoping that my fear will fade, but instead it only intensifies.

It’s the same pain, the same fear, that pulled me away from fiction writing. I want to go back, I hope to go back—but I am not strong enough now, and cannot be sure I ever will be. I was told that working in a creative profession meant working hard and producing good output; it turns out it doesn’t mean that at all. A successful career in a creative field actually means satisfying the arbitrary desires of a handful of inscrutable gatekeepers. It means rolling the dice over, and over, and over again, each time a little more painful than the last. And it turns out that this just isn’t something I’m good at. It’s not what I’m cut out for. And maybe it never will be.

An incompetent narcissist would surely fare better than I, willing to re-submit whatever refuse they produce a thousand times because they are certain they deserve to succeed. For, deep down, I never feel that I deserve it. Others tell me I do, and I try to believe them; but the only validation that feels like it will be enough is the kind that comes directly from those gatekeepers, the kind that I can never get. And truth be told, maybe if I do finally get that, it still won’t be enough. Maybe nothing ever will be.

If I knew that it would get easier one day, that the pain would, if not go away, at least retreat to a dull roar I could push aside, then maybe I could stay on this path. But this cannot be the rest of my life. If this is really what it means to have an academic career, maybe I don’t want one after all.

Or maybe it’s not academia that’s broken. Maybe it’s just me.

Mental illness is different from physical illness.

pnrj cognitive science, personal , , , , , , , , , , , ,

Post 311 Oct 13 JDN 2458770

There’s something I have heard a lot of people say about mental illness that is obviously well-intentioned, but ultimately misguided: “Mental illness is just like physical illness.”

Sometimes they say it explicitly in those terms. Other times they make analogies, like “If you wouldn’t shame someone with diabetes for using insulin, why shame someone with depression for using SSRIs?”

Yet I don’t think this line of argument will ever meaningfully reduce the stigma surrounding mental illness, because, well, it’s obviously not true.

There are some characteristics of mental illness that are analogous to physical illness—but there are some that really are quite different. And these are not just superficial differences, the way that pancreatic disease is different from liver disease. No one would say that liver cancer is exactly the same as pancreatic cancer; but they’re both obviously of the same basic category. There are differences between physical and mental illness which are both obvious, and fundamental.

Here’s the biggest one: Talk therapy works on mental illness.

You can’t talk yourself out of diabetes. You can’t talk yourself out of myocardial infarct. You can’t even talk yourself out of migraine (though I’ll get back to that one in a little bit). But you can, in a very important sense, talk yourself out of depression.

In fact, talk therapy is one of the most effective treatments for most mental disorders. Cognitive behavioral therapy for depression is on its own as effective as most antidepressants (with far fewer harmful side effects), and the two combined are clearly more effective than either alone. Talk therapy is as effective as medication on bipolar disorder, and considerably better on social anxiety disorder.

To be clear: Talk therapy is not just people telling you to cheer up, or saying it’s “all in your head”, or suggesting that you get more exercise or eat some chocolate. Nor does it consist of you ruminating by yourself and trying to talk yourself out of your disorder. Cognitive behavioral therapy is a very complex, sophisticated series of techniques that require years of expert training to master. Yet, at its core, cognitive therapy really is just a very sophisticated form of talking.

The fact that mental disorders can be so strongly affected by talk therapy shows that there really is an important sense in which mental disorders are “all in your head”, and not just the trivial way that an axe wound or even a migraine is all in your head. It isn’t just the fact that it is physically located in your brain that makes a mental disorder different; it’s something deeper than that.

Here’s the best analogy I can come up with: Physical illness is hardware. Mental illness is software.

If a computer breaks after being dropped on the floor, that’s like an axe wound: An obvious, traumatic source of physical damage that is an unambiguous cause of the failure.

If a computer’s CPU starts overheating, that’s like a physical illness, like diabetes: There may be no particular traumatic cause, or even any clear cause at all, but there is obviously something physically wrong that needs physical intervention to correct.

But if a computer is suffering glitches and showing error messages when it tries to run particular programs, that is like mental illness: Something is wrong not on the low-level hardware, but on the high-level software.

These different types of problem require different types of solutions. If your CPU is overheating, you might want to see about replacing your cooling fan or your heat sink. But if your software is glitching while your CPU is otherwise running fine, there’s no point in replacing your fan or heat sink. You need to get a programmer in there to look at the code and find out where it’s going wrong. A talk therapist is like a programmer: The words they say to you are like code scripts they’re trying to get your processor to run correctly.

Of course, our understanding of computers is vastly better than our understanding of human brains, and as a result, programmers tend to get a lot better results than psychotherapists. (Interestingly they do actually get paid about the same, though! Programmers make about 10% more on average than psychotherapists, and both are solidly within the realm of average upper-middle-class service jobs.) But the basic process is the same: Using your expert knowledge of the system, find the right set of inputs that will fix the underlying code and solve the problem. At no point do you physically intervene on the system; you could do it remotely without ever touching it—and indeed, remote talk therapy is a thing.

What about other neurological illnesses, like migraine or fibromyalgia? Well, I think these are somewhere in between. They’re definitely more physical in some sense than a mental disorder like depression. There isn’t any cognitive content to a migraine the way there is to a depressive episode. When I feel depressed or anxious, I feel depressed or anxious about something. But there’s nothing a migraine is about. To use the technical term in cognitive science, neurological disorders lack the intentionality that mental disorders generally have. “What are you depressed about?” is a question you usually can answer. “What are you migrained about?” generally isn’t.

But like mental disorders, neurological disorders are directly linked to the functioning of the brain, and often seem to operate at a higher level of functional abstraction. The brain doesn’t have pain receptors on itself the way most of your body does; getting a migraine behind your left eye doesn’t actually mean that that specific lobe of your brain is what’s malfunctioning. It’s more like a general alert your brain is sending out that something is wrong, somewhere. And fibromyalgia often feels like it’s taking place in your entire body at once. Moreover, most neurological disorders are strongly correlated with mental disorders—indeed, the comorbidity of depression with migraine and fibromyalgia in particular is extremely high.

Which disorder causes the other? That’s a surprisingly difficult question. Intuitively we might expect the “more physical” disorder to be the primary cause, but that’s not always clear. Successful treatment for depression often improves symptoms of migraine and fibromyalgia as well (though the converse is also true). They seem to be mutually reinforcing one another, and it’s not at all clear which came first. I suppose if I had to venture a guess, I’d say the pain disorders probably have causal precedence over the mood disorders, but I don’t actually know that for a fact.

To stretch my analogy a little, it may be like a software problem that ends up causing a hardware problem, or a hardware problem that ends up causing a software problem. There actually have been a few examples of this, like games with graphics so demanding that they caused GPUs to overheat.

The human brain is a lot more complicated than a computer, and the distinction between software and hardware is fuzzier; we don’t actually have “code” that runs on a “processor”. We have synapses that continually fire on and off and rewire each other. The closest thing we have to code that gets processed in sequence would be our genome, and that is several orders of magnitude less complex than the structure of our brains. Aside from simply physically copying the entire brain down to every synapse, it’s not clear that you could ever “download” a mind, science fiction notwithstanding.

Indeed, anything that changes your mind necessarily also changes your brain; the effects of talking are generally subtler than the effects of a drug (and certainly subtler than the effects of an axe wound!), but they are nevertheless real, physical changes. (This is why it is so idiotic whenever the popular science press comes out with: “New study finds that X actually changes your brain!” where X might be anything from drinking coffee to reading romance novels. Of course it does! If it has an effect on your mind, it did so by having an effect on your brain. That’s the Basic Fact of Cognitive Science.) This is not so different from computers, however: Any change in software is also a physical change, in the form of some sequence of electrical charges that were moved from one place to another. Actual physical electrons are a few microns away from where they otherwise would have been because of what was typed into that code.

Of course I want to reduce the stigma surrounding mental illness. (For both selfish and altruistic reasons, really.) But blatantly false assertions don’t seem terribly productive toward that goal. Mental illness is different from physical illness; we can’t treat it the same.