This book is by a Swedish professor of philosophy who has affiliations with the well-known British psychiatrist and philosopher Professor Fulford of the University of Warwick. It is about the perennial question of what constitutes the essence of a psychiatric disorder, either at the level of descriptive psychopathological entities such as delusion, or nosological entities such as psychopathy or drug addiction.
The first part of the title – rationality and compulsion – refers to his central thesis, which is that irrationality is an insufficient criterion of the essence of a psychiatric disorder which he is seeking, chiefly because all sorts of people behave irrationally during their lives and are not otherwise psychiatrically disordered, whereas in all the psychiatric disorders that he considers – delusion, kleptomania, pyromania, drug addition, ‘rigid personality’ and psychopathy – the subject is under a compulsion to act as he or she does.
The second part of the title – applying action theory to psychiatry – is the set of philosophical arguments which he uses to arrive at the above central thesis.
To my mind, his conclusion is largely correct, although I would phrase it differently, but his argumentation in arriving at it is largely incorrect. I shall concentrate on these two points in the rest of this review.
There is a theme running through French and German psychopathology and represented by some of its greatest exponents – Henri Ey, Blankenburg, Tellenbach, Kraus – to the effect that what makes a set of beliefs or actions or an emotional state morbid, and hence a ‘psychiatric disorder’ as opposed to some understandable reaction, is the lack of freedom – ‘pathologie de la liberte’ (Ey), ‘not being able to behave differently’ (Blankenburg) – that any such mental state engenders. The Anglo-American tradition, which is codified in the DSMs, is rather to take the pragmatic view of looking for harm to self or others in such categorizations. This latter approach leads into all sorts of paradoxes, as Fulford, in particular, has pointed out. I am all for the continental approach on this issue, one, I might add, which most British psychiatrists will probably never have heard of. It was not mentioned once to me in all my years of training. Nordenfelt's thesis here is more or less spot on for the conditions he covers, although the term ‘compulsion’ is not general enough. I prefer the term ‘constraint’, because some psychiatric disorders have nothing to do with being compelled to act in this or that way, for example, many deluded people do not act on their delusions anyway, and the mood of someone in a depressive illness or anxiety neurosis is no less morbid for their having the mood that they have and cannot help rather than some overwhelming urge to burn their house down. They are constrained in how they can feel, as yet others are constrained in how they can think or perceive. Moreover, the notion of constraint can be carried over into a neuropsychological analysis of disease: for example, a lesion in Broca's area constrains your communication skills; it does not compel you to silence.
On the second issue, of what constitutes action and why actions occur, I am not in agreement with the author at all. Even though his arguments on all this take up most of the book, and he only deals with psychiatry in the last chapter, I do not think that psychiatrists would be much interested in the philosophy of action even if it were correct.
Altogether, however, it is a readable book, and as a spur to thinking about nosology and why, for example, a depressive illness is an illness and not understandable misery, it is definitely worth reading for the last chapter alone.
