Madness as Dysfunction

Madness-as-dysfunction is the view that mental disturbance is the mind, the brain, or one of their parts failing to do what it is supposed to do. On this picture, when someone is mad, something inside that person has gone wrong: a faculty has failed, a humor is corrupted, a brain circuit is misfiring, an evolved mechanism is producing the wrong output. The view runs from the Hippocratic authors of the fifth century BCE, through Kant and the German psychiatrists of the nineteenth century, into the DSM-III of 1980 and the Research Domain Criteria project of the National Institute of Mental Health.(Garson, 2022) Justin Garson’s 2022 Madness: A Philosophical Exploration identifies it as one of two competing thought styles that have shaped Western thinking about mental disturbance, and argues that during the twentieth century it became so entrenched in academic psychiatry that any departure from it began to look conceptually incoherent rather than merely wrong.

Working Definition

Garson formulates the axiom of madness-as-dysfunction with one sentence: “when someone is mad, it is because something has gone wrong inside of that person.”(Garson, 2022) On this view the mind has parts (faculties, functions, brain regions, evolved modules); each part has a job; madness is what happens when one or more of those parts cannot do its job. The opposing view, madness-as-strategy, holds the opposite: that madness is a purpose being fulfilled.

The distinction is not the same as the older split between biogenic and psychogenic accounts of mental illness. A dysfunction-style account can be biological (Griesinger’s brain disorders, the DSM-III’s biological dysfunctions) or non-biological (Kant’s mental faculties, with no clear biological grounding). What unifies dysfunction-style accounts is the structural assumption that the symptom is a miscarriage of function, not the function operating as it should.(Garson, 2022) The split is between teleology and dysteleology, accomplishment and miscarriage.

The two traditions are not chronologically successive. They have always coexisted, and most actual thinkers exhibit some intermingling of both, with one or the other holding a slight cultural edge in different eras.(Garson, 2022)

The Hippocratic Origin

The earliest fully developed case of dysfunction-style thinking that Garson treats is the Hippocratic author of On the Sacred Disease. The conventional reading frames the Hippocratic break from the magicians as naturalism over supernaturalism, but Garson argues the real distinction is teleological. The Hippocratics held a body composed of organs each with its proper function; disease was the failure of those organs to perform their work. Epilepsy was caused by air trapped in the veins by phlegm, with seizure symptoms tied to which body parts were deprived of air.(Garson, 2022) Madness in general was differentially diagnosed by the relevant humor: phlegmatic madness produced quietness, bilious madness produced restless agitation, and changes in brain temperature produced terrors and fears.(Garson, 2022) On the Hippocratic picture, disease has no goal and no end. It is the perversion of the creature’s ability to carry out its functions.(Garson, 2022)

Early Modern Interlude: Hysteria and Dysfunction within Teleology

Before the Kantian systematization, the early modern period shows dysfunction-style thinking operating under pressure from a still-dominant teleological cosmos. Edward Jorden’s 1603 account of suffocation of the mother (hysteria) functioned, in Garson’s reading, as a vacuous explanatory template: a form without content that medicalized any female mental disturbance by attributing it to the womb, without specifying what the womb’s supposed mischief actually accomplished.(Garson, 2022) Yet Jorden did not simply replace teleology with dysfunction; he carved out space for dysteleology inside a divinely ordered universe, so that madness-as-dysfunction operated freely within a teleological cosmos, like a virus inside its host.(Garson, 2022) The possibility of dysfunction within teleology, rather than in place of it, is a structural feature that would continue to surface in later thinkers who officially endorsed the dysfunction picture while letting purposive language re-enter.

Kant and the Faculties of the Sound Mind

The dysfunction picture became a systematic doctrine in Kant’s youthful Essay on the Maladies of the Head (1764).(Garson, 2022) Kant’s signal contribution was the principle that each form of madness is the failure of a corresponding faculty of the sound mind. The faculties form a complete and closed system, and so do the basic forms of madness; one can grasp both a priori, without empirical investigation. Kant named three faculties (experience, judgment, reason) and three corresponding forms of madness: Verrueckung (derangement of experience), Wahnsinn (dementia of judgment), and Wahnwitz (insanity of reason).(Garson, 2022) (Garson, 2022)

This was a sharp break from Kant’s contemporary nosologists (Linnaeus, Boissier de Sauvages, Cullen), whose taxonomies were empirical and open-ended. A philosopher who announced that there must be exactly twelve kinds of plant in the world, with such-and-such specific features, would be laughable. But Kant proposed exactly three forms of madness because there are exactly three faculties of the mind.(Garson, 2022)

The clinical consequence of this framework, on Garson’s reading, was that madness was silenced. The mad person’s words and actions no longer carried truth of their own; they became clues to a hidden dysfunction. Foucault’s phrase, which Garson cites approvingly, is that madness “ceased to be a sign of another world” and was restored “to the truth of its emptiness.” Where earlier traditions had asked what the symptom was for, the Kantian framework asked only which faculty had failed.(Garson, 2022)

By 1798, in his mature Anthropology, Kant had begun to import teleology back into his account, against his earlier framework. Affect became a “temporary surrogate of reason”; even at the height of insanity, nature implants systematizing tendencies “so that the faculty of thought does not remain idle.” Garson reads this as a sign of how hard pure dysfunctionalism is to hold consistently. Even Kant, the framework’s clearest expositor, kept finding teleology in madness.(Garson, 2022)

The Mid-Eighteenth Century Shift

By the mid-eighteenth century a new consciousness of madness had emerged in European thought: madness as mere pathology, as breakdown rather than as having any truth of its own to reveal.(Garson, 2022) This shift was expressed in a new style of classification that first surveyed the faculties of the sound mind (reason, imagination, memory, judgment, will, perception) and then enumerated forms of madness as the ways those faculties could fail.(Garson, 2022) The method was not Kant’s a priori deduction, but it shared Kant’s structural assumption that the inventory of dysfunction is derived from the inventory of healthy function.

Haslam and Wigan: Dysfunction with a Telos

John Haslam, apothecary at Bedlam from 1795 to 1816, accepted Kant’s picture and added a new feature: dissimulation. The mad, Haslam argued, must always exhibit diminution or perversion of mental faculties; augmentation would be a mark of genius, not insanity.(Garson, 2022) Madness had an organic basis (Haslam carried out dozens of autopsies and added an a priori demonstration: since the soul is incorruptible, the disorder must reside in physical substance).(Garson, 2022)

Haslam’s signature contribution, and a problem his framework had to solve, was that mad patients often appeared reasonable. James Tully Matthews, held at Bedlam from 1797 until his death in 1815, had family-commissioned outside doctors declare him sane in 1809; Haslam responded by assembling London’s top physicians to issue a counter-deposition. To explain how a mad person could appear sane, Haslam posited dissimulation: the mad person understands but is not compelled by reason, the way a psychopath grasps but is not motivated by moral propositions.(Garson, 2022) Madness, on this picture, has the structure of a parasite that changes its protein coat to evade detection. The clinical method follows: protract conversations until the patient tires of feigning reason and lets a favorite delusional theme surface.(Garson, 2022)

Garson treats this as illustrative of how teleology kept resurfacing inside dysfunction-style frameworks. Haslam’s dysfunction has acquired a new telos: the goal of feigning reason in order to evade detection. The framework is officially dysteleological but has smuggled purpose back in.

Arthur Wigan’s A New View of Insanity (1844) offered a more thoroughgoing alternative, arguably the most teleological of the nineteenth-century theorists. But Wigan’s project is described in detail on the Madness as Strategy page; here it is enough to note that even within nineteenth-century British psychiatry, the dysfunction framework was contested by figures who saw reason and madness as inseparable structural features of any human mind.

The German Biologization

Wilhelm Griesinger’s Die Pathologie und Therapie der psychischen Krankheiten (1845) flattened Kant’s two-layer ontology of mind and body into a single biological entity. Mental faculties became brain organs; the functions of those organs became the functions of the mind. There was no longer a relation between brain states and mental faculties; there was simply the brain, embedded in the nervous system as a whole.(Garson, 2022) Garson calls this “the biologization of Kant”: the same dysfunction-style framework, now grounded in materialist neuroscience.

The era of “German imperial psychiatry,” running from Griesinger’s textbook to the simultaneous 1899 publications of Kraepelin’s sixth edition and Freud’s Interpretation of Dreams, was defined by the fusion of two doctrines: that madness is biological, and that madness is dysfunctional.(Garson, 2022) For Griesinger the brain’s purpose was to compile a library of sensorimotor contingencies: figuring out which motor output to produce in response to which sensory input. All other faculties (memory, imagination, motivation) were subsidiary to this central task.(Garson, 2022) Insanity was defined by calibration: the mind producing dispositions, emotions, and ideas autonomously from the world rather than under the proper sway of external reality.

Griesinger himself, like Kant before him, found teleology re-entering through the back door; his account of delusions and dreams as wish-fulfillments anticipated Freud. But Emil Kraepelin radicalized the dysfunction program. For Kraepelin, madness and teleology were logically exclusive. The only purposiveness available was the purposiveness of conscious intention, so any apparent goal-directedness in a mad patient’s symptoms had to be malingering.(Garson, 2022) Kraepelin diagnosed acquired neurasthenia as artful malingering; he described chronic neurasthenic invalids’ withdrawal into hospitals and their “assumed contortions” as strategy for perpetuating the sick role.(Garson, 2022) The First World War’s Kriegszitterer (the “war shakers” of the German army) initially struck Kraepelin as malingerers exploiting public sympathy; he softened by 1917 after seeing hypnosis work, but maintained that war neurosis revealed a fundamentally weak character.(Garson, 2022)

Kraepelin also reframed psychiatric classification as a propaedeutic to discovering disease mechanisms. Tracing the chronological course of an illness, dementia praecox for instance, would constrain hypotheses about the underlying neuropathic entity. In the philosopher of science’s vocabulary, disease categories became mechanism-sketches.(Garson, 2022)

The DSM-III and the Triumph of Dysfunction

The standard story about the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (1980) is that it represented a biological turn in American psychiatry, a victory of medicine over Freudian psychoanalysis. Garson rejects this reading. The DSM-III’s definition of mental disorder explicitly admitted “behavioral, psychological, or biological dysfunctions”; the manual was domain-neutral on the question of biology. What the DSM-III actually accomplished, on Garson’s argument, was not a shift from psychogenic to biogenic psychiatry but the abolition of teleology as the organizing concept of psychiatric classification.(Garson, 2022) (Garson, 2022) The DSM-I of 1952 had defined psychotic, neurotic, and personality disorders as three different strategies the personality uses for adjustment to internal and external stress. Adolf Meyer’s term “reaction” (anxiety reaction, conversion reaction) designated a goal-directed coping mechanism. Successive editions, DSM-II in 1968 and especially DSM-III in 1980, systematically purged this language.(Garson, 2022)

The DSM-III appeal to dysfunction had three structural features. Intrinsicality: the disorder is something in the person, not in their relation to society. Domain neutrality: the dysfunction can be biological, psychological, or behavioral. Dysteleology: the inner condition represents a way of going wrong, judged by a standard internal to function rather than by social norms.(Garson, 2022) The framework was also doubled: a manifest syndrome must cause an impairment in some “area of functioning” (work, school, social relations) AND must reflect an inner dysfunction. Two failures, the inner causing the outer.(Garson, 2022)

The historical context helps explain the appeal. In March 1973 Walter Barton, then chief executive of the American Psychiatric Association, sent a memo calling for a Task Force to Define Mental Illness. The very perceived need for such a definition, Garson argues, indicates a profession under existential threat: from Szasz, from anti-psychiatry, from sociologists of medicine, from rival psychologists. The dysfunction definition served a defensive function: it certified that mental disorders are diseases, and therefore that psychiatrists, as physicians, have the special authority to delineate and treat them.(Garson, 2022) (Garson, 2022)

The DSM-III attempted to ground its dysfunction concept in three nested ways, each more philosophically ambitious than the last.

R. E. Kendell, drawing on John Scadding, defined disease as a condition placing its bearer at “biological disadvantage”: typically increased mortality or reduced fecundity. On this criterion, schizophrenia and homosexuality were both diseases. But the criterion ran into difficulties: if the disadvantage came from social stigma rather than intrinsic dysfunction, the criterion would pathologize whatever a society happened to disapprove of. Kendell’s attempt to refine the notion via “innate biological disadvantage” collapsed under counterfactual indeterminacy and the relational nature of evolutionary fitness.(Garson, 2022) (Garson, 2022)

Robert Spitzer and Jean Endicott offered a different operationalization: a list of culturally recognized impairments (perception, reproduction, cosmetic appearance, sexual pleasure in interpersonal context). The careful choice of “interpersonal” rather than “heterosexual” allowed the manual to remove homosexuality from the disease list in 1973 without contradiction.(Garson, 2022)

Donald Klein offered the most evolutionary version: mental disorder as failure of evolved design. Garson notes Klein’s striking confidence that evolution would justify the existing list of mental disorders (schizophrenia, depression, antisocial personality disorder) as design failures. The confidence was striking because the same evolutionary framework could equally well support viewing those conditions as adaptations rather than failures.(Garson, 2022)

Jerome Wakefield’s 1992 paper completed the dysfunction project at the conceptual level. Wakefield argued that as a matter of conceptual analysis, all disorders are harmful dysfunctions: a logical truth like “all bachelors are unmarried men.” Dysfunction, on his account, is failure to do what natural selection shaped a trait to do. Wakefield’s account adopted the selected-effects theory of biological function (developed by Edmond Goblot, later by Larry Wright, Karen Neander, and Ruth Millikan) and turned it into a defining property of all disorder.(Garson, 2022) (Garson, 2022) The fact that such an analysis could appear, Garson observes, is itself a marker of how completely the dysfunction style had displaced its rival within forty years. Mainstream psychiatry in 1952 had treated madness-as-strategy as standard; by 1992 the same view was being claimed as conceptually impossible.(Garson, 2022)

Garson draws a pointed conclusion from this arc: the DSM-III framework ultimately defines the patient not as a citizen or a person embedded in social relations, but as a wounded organism whose disorder is judged by the standard of life itself — with evolution serving as the ultimate adjudicator of dysfunction.(Garson, 2022)

RDoC and the Return to Kant

Garson reads the Research Domain Criteria project, launched by the National Institute of Mental Health under Thomas Insel, not as a competitor to the DSM but as its fulfillment. RDoC abandons syndrome-based classification entirely. It begins with a characterization of the healthy mind as composed of six functional “domains” (negative valence, positive valence, cognitive, social, arousal/regulatory, sensorimotor systems) and treats pathology as failure of constructs within these domains. Garson sees this as a return to Kant in pure form: a complete and closed system of mental faculties from which the basic forms of madness can be enumerated as failures of those faculties.(Garson, 2022)

The Cultural Authority of the Framework

Garson’s broader argument is sociological as well as historical. By the late twentieth century, madness-as-dysfunction had become what Ludwik Fleck called a Denkstil: a thought style with such firm grip on the mind that any departure from it appears not merely wrong but inconceivable.(Garson, 2022) The framework had succeeded so completely that philosophers of medicine like Wakefield and Christopher Boorse could convert its historical entrenchment into apparent logical necessity.(Garson, 2022)

Garson’s response, throughout the book, is to make the framework visible as a tradition rather than a default. The point is not that madness-as-dysfunction is wrong; some forms of madness almost certainly involve dysfunction in some respect. The point is that pure dysfunction is rare in biology generally; the same trait can be dysfunctional in some respects and functional in others, as fever during influenza is both a viral dysfunction and an adaptive immune response.(Garson, 2022) Goldstein’s warning, Garson notes, is that it is easy to mistake a teleological performance for a dysteleological one: the Babinski reflex in adults is typically read as corticospinal dysfunction, but Goldstein argued it is also an expression of the goal-directed activity of flight from danger.(Garson, 2022) Where the dominant framework treats dysfunction as the silent default, Garson argues the framework should be made to coexist with alternatives, to be in his phrase a good citizen rather than a sole occupant.

Specific Tensions

Several specific places in the dysfunction tradition show the framework under strain.

The DSM-III’s appeal to dysfunction was meant to be a defining property of mental disorder, but as the Kendell/Klein/Wakefield sequence shows, the conceptual content of “dysfunction” remained unstable. Each attempt to ground the notion encountered an objection that the same evolutionary framework could equally support viewing the relevant conditions as adaptations rather than failures.

The framework also has political implications that Pinel had already identified in 1800. Pinel argued that the brain-dysfunction view of madness is itself part of the structural pattern of asylum cruelty: regarding the mad as having a brain lesion encourages sequestering them and refusing them ordinary care.(Garson, 2022) Haslam’s actual clinical practice illustrated this logic from the opposite direction: where Pinel advocated moral treatment, Haslam advocated stifling manic attacks through profuse bleeding (preferably from the scalp) and dark-room restraint, on the grounds that each attack reinforces madness by forging new pathological associations in the brain.(Garson, 2022) The therapeutic corollary of the dysfunction framework is that the patient’s own experience has no curative role; what must be corrected is a physical process, not a meaning. Whether or not this argument generalizes to contemporary contexts, it indicates that the dysfunction framework is not politically neutral.

Finally, even when the framework has cultural authority, individual thinkers within it often slip back into teleological language. Kant’s Anthropology, Griesinger’s wish-fulfillments, Haslam’s dissimulation-with-purpose, and Goldstein’s organism-with-narrowed-jurisdiction all show teleology re-entering. The pattern Garson identifies is that pure dysfunctionalism is hard to hold consistently for long; the explanatory work demanded by clinical experience keeps pulling toward purposive language.

See Also

• Madness as Strategy
• Justin Garson
• Anti-Psychiatry
• Hippocratic Medicine
• Immanuel Kant
• Emil Kraepelin
• DSM-III
• Faculty Psychology
• Philippe Pinel
• Harmful Dysfunction

Sources

All claims cite evidence cards from:

• Garson, J. (2022). Madness: A Philosophical Exploration. Oxford: Oxford University Press. [Source ID: garson-madness-philosophical-exploration-2022]

Editorial Notes

Gaps the encyclopaedia compiler flagged for future evidence work, collected from inline markers in the body and frontmatter.

Specific Tensions