Social Construction, Biological Design, and Mental Disorder

Pierre-Henri Castel provides a short but richly argued precis of his recently published two-volume 1,000-page masterwork on the history of obsessive-compulsive disorder (OCD). Having not read the as-yet-untranslated books, I write this commentary from Plato’s cave, trying to infer the reality of Castel’s analysis from expository shadows. I am unlikely to be more successful than Plato’s poor troglodytes, so I apologize ahead of time for any misunderstandings. Moreover, I cannot assess Castel’s detailed evidential case for his substantive theses.¹ I thus focus on some key philosophical issues that impinge on an area of my concern, the concept of mental disorder.

Castel is a rare breed of French psychoanalyst/philosopher who also possesses detailed command of Anglo-American analytic philosophy of mind.² His work, I argue, provides an exceptional opportunity for a constructive philosophy-of-psychiatry dialogue across the analytic/continental divide.

OCD and the Social Construction of Autonomy and Self-control

Castel’s basic substantive theses, lucidly presented, are, first, that a central psychological construction of our culture is the creation of a personal sense of autonomy and a corresponding inner mental space in which that autonomy dominates over desire. Second, what we call OCD is an extreme form or side effect of our culture’s relentless ‘civilizing of the mind’ in quest of this sense of autonomy, a quest which takes the form of the cultivation of self-control of desire:

Put simply, the ‘dark side’ of autonomy is excessive self-constraint: it is what occurs in societies when repression of instinct and the encouragement of work and obedience is accomplished, not by external constraint or threats of violence but through the interiorization of forms of self-control….all this accompanied by the sense of existing in a sort of private inner space.³

(Castel 2014, 302)

Castel’s characterization of obsessive thinking as a manifestation of a general struggle for control over unwanted thoughts and desires that stretches from a general cultural phenomenon to a mental disorder is reflected in DSM-5’s broad definition of obsessions that requires “recurrent and persistent thoughts, urges, or images that are…intrusive and unwanted, and that in most individuals cause marked anxiety or distress” that “the individual attempts to ignore or suppress” (American Psychiatric Association 2013, 237). Taken literally and interpreted broadly, this characterization encompasses the continual process of self-control over unwanted/distracting/disapproved/distressing sexual, eating, aggressive, and other impulses, and over distracting thoughts unrelated to the details of work or school. OCD in this sense is the distillation of a culturally shaped process that permeates our lives.

However, psychiatrists are not conceptual analysts, and many DSM descriptions are conceptually flawed and overshoot the mark of what they are intended to capture (Wakefield 1997; 2010; Wakefield and First 2003). The actual intended domain of OCD in psychiatric practice is much smaller than an expansive reading of the DSM-5 definition indicates. Is that narrower classic domain genuinely a mental disorder? Castel maintains an ambiguous stance on the answer to this question, perhaps to protect his claim that he is not pursuing the Foucauldian methodology of using pathology to reveal norms. However, the question deserves a clear answer, to which I return below.

Castel argues that psychiatry’s approach to OCD and, correspondingly, society’s approach to the general pursuit of self-control, is presently at an inflection point. The Freudian dynamic required a search for equanimity in a social universe that disallowed the expression of many ineradicable natural desires. Freudian theory thus addressed inherent conflict between individual and society or its internalized representatives. In contrast, both cognitive behavior therapy and brain-oriented therapies largely ignore conflict and assume that lack of control is inherently pathological.

Castel’s identification of this shift seems persuasive. In my experience, this shift is apparent in discussions of the boundaries of psychopathology, in which self-regulation and self-control increasingly are...