The Order of Disorder

When assessing a new philosophical theory of psychopathology, a first question might be: is it descriptive or revisionary in intent? Does it aim to provide reflective understanding of what is already meant by correct uses of ‘mental disorder’? Or instead to redeploy that familiar term in articulating a new concept meeting particular desiderata? Nielsen offers us an ‘enactive conceptualization’ of mental disorder, and conceptualizations are typically understood as inventive rather than descriptive. However it was not entirely clear to me, from reading his text, that this was indeed his ambition. My first question for Nielsen, then, is clarificatory: does he intend his project as descriptive or revisionary?

If the intention is to supply a revision of our concept, then criticisms of the conceptualization for deviating from what we currently understand will be less apt. It may, however, be considered significant if it deviates too much. We will at least then be particularly keen to assess whether the revision is sufficiently motivated. What was wrong with our old concept? What ends does the new conceptualization aim at meeting that the old one could not? (If Nielsen takes his conceptualization as revisionary, this constitutes my next question for him.) What, in short, is the point of it?

Nielsen’s scheme has it that conditions are to be called mental disorders if having them involves acting in such ways as actively go against realizing the ambition to survive and adapt. As he puts it, the imperative of this ambition “affords a purpose against which … behavior can be evaluated,” giving us a criterion for distinguishing between the mentally functional and the dysfunctional, and thereby a criterion for mental disorder. What I wondered at this point (my third question) is why–unlike Freud, say–Nielsen restricts attention to such evolution-provided drives as promote individual survival–rather than also including reproduction and the survival of progeny. Presumably there is at play here something principled, rather than a mere wish to avoid the awkwardness of diagnosing nuns and homosexuals as mentally disordered, but I could not reconstruct it from the text.

My next question proceeds from the assumption that Nielsen wants either to map our existing concept, or at least to provide something which largely resembles it. So, it is, as just mentioned, part of his proposal that mental disorders essentially involve behavior contrary to one’s survival. It is, however, a long-standing observation in psychiatry that ‘Madness is in itself very little prejudicial to animal life. For it is notorious that men really mad live as long as those who are perfectly in their senses’ (Battie, 1758). Or ‘Patients with so-called functional mental disorders, die, not from their mental illness, but from other causes’ (Alzheimer, 1910). It is also worth noting the long tradition in psychiatry of understanding madness as itself pursuing the end of preserving life: ‘Now if such a sorrow, such painful knowledge or reflection, is so harrowing that it becomes positively unbearable, and the individual would succumb to it, then nature, alarmed in this way, seizes upon madness as the last means of saving life. The mind, tormented so greatly, destroys, as it were, the thread of memory, fills up the gaps with fictions, and thus seeks refuge in madness from the mental suffering that exceeds its strength.’ (Schopenhauer, 1818/1969; see also Garson, 2019, chapter 10). The fourth question, then, asks whether a survival-indexed concept of mental disorder bears enough resemblance to our ordinary concept of mental disorder to warrant it sharing the same name. We may also ask here whether we really want to call every instance of suicide, or of engaging in extreme sport, the act of a mentally disordered person.

It should be noted that, in an elaboration of his scheme, it is not only evolution, but also society, that Nielsen credits with providing the functional norms by reference to which disorder is to be judged present. Elsewhere (Nielsen & Ward, 2020) he refines the proposed relation between social norm and mental disorder by distinguishing between such of a society’s functional norms as serve an individual’s adaptive functioning and those which...