Wakefield's hybrid account of mental disorder

Wakefield's question is what makes a mental condition a disorder. He formulates the question in two different ways: a) "What do we mean when we say that a mental condition is a medical disorder rather than, for instance, a normal form of human suffering?" and b) "Which mental conditions should be classified as pathological?" The latter question is far more significant, especially if we concede that no consensus exists on the meaning of "mental disorder". "Disorder" is regarded as a broad term "that covers both traumatic injuries and diseases/illnesses". This notion is more practically significant than, for instance, the notion of disease. The distinction between disease and injury has no practically important consequences, whereas the distinction between disorder and non-disorder can affect who is entitled to publicly funded health care, medical insurance reimbursement, or sick leave with compensation (1,2).

In Wakefield's view, mental disorders are harmful mental dysfunctions. This is presented as a hybrid account, i.e., as incorporating both a value component (harm) and a factual component (dysfunction). It is not clear whether Wakefield's account contains any value component, however, i.e., whether it is a proper hybrid account. Wakefield repeatedly uses phrases like "judged negative by sociocultural standards" or "harmful according to social values" to characterize the value component, but to say that a condition is deemed negative by "sociocultural standards" is really a factual statement. Moreover, to refer to existing sociocultural standards is only relevant if we want to explain why certain conditions are classified as disorders in a certain society, but not if we want to determine what conditions should be classified as pathological. The latter question is the important one and, to answer this question, we need to determine whether a condition is harmful, not whether it is regarded as such from any particular perspective. But let us assume that Wakefield's analysis is, in fact, a proper hybrid account. In this case, his account of the value component is probably too narrow, and the same holds for his account of the factual component.

Mental disorders typically involve some kind of harm to the individual who has the disorder, e.g. distress or disability, and we rely rather heavily on considerations of harm when drawing the line between disorder and non-disorder. This strongly suggests that the connection between disorder and harm is conceptual rather than contingent. Wakefield makes a stronger point than this, however, namely that harm to the individual is necessary for disorder, and that we need not rely on any other evaluative considerations to delineate the class of mental disorder. However, it seems that there are mental disorders that are classified as disorders in virtue of other evaluative considerations, e.g., that paedophilia and antisocial personality disorder count as disorders because they are abnormal and/or harmful to others. This suggests that we should not draw the line between disorder and non-disorder on the basis of harm-forthe- individual-evaluations alone, but that we must also make use of harmfulfor- others-judgments and judgments of abnormality, including attributions of irrationality (3). This view gives us a less coherent concept of mental disorder, however, and it is incompatible with the idea that "mental disorder" can be defined in terms of necessary conditions that are jointly sufficient (3). Wakefield's evolutionary account of disorder has been heavily criticized (1,4- 7). Most objections purport to show that dysfunction (in Wakefield's sense) is not necessary for disorder, i.e. that someone may well suffer from a disorder even when there is no "evolutionary malfunction". Some of these objections try to establish that "many mental functions are not direct evolutionary adaptations, but rather adaptively neutral by-products of adaptations" (4), and that some disorders involve failed mechanisms that have no adaptive function, like spandrels, exaptations, or vestigal parts.

Other arguments purport to establish that disorders can be caused by mechanisms that are working exactly as designed by evolution, e.g., that some disorders are evolutionary adaptive reactions to "pathogenic inputs". Injuries due to external trauma involve dysfunctions, however, and so do inflammatory reactions, infectious diseases, and posttraumatic stress disorder. But consider "normal grief" vs. pathological bereavement (a possible component in depressive disorder) as two possible reactions to loss. Is the difference between these conditions really that some specific mechanism is malfunctioning in the second case but not in the first? To defend the dysfunction account by postulating a "loss-response mechanism" is rather farfetched. It seems more plausible to regard the two conditions as different ways of functioning, where "the depressed way of grieving" is far more harmful than the "normal" way. This suggests that the presence of a dysfunction is not essential to disorder. Moreover, the exclusion of normal grief from the class of mental disorder can be questioned: for instance, it might be appropriate to regard grief as a mental injury and, if all injuries are disorders, so is grief. It can also be argued that people in grief are entitled to sick leave with compensation. Normality is simply not the issue here.

To conclude, Wakefield's idea that disorders are dysfunctions (defined in evolutionary terms) tends to exclude too much from the category of mental disorder. There are alternative views, but these views also suffer from certain weaknesses (1). This strongly suggests that we cannot save our linguistic intuitions unless we abandon the idea that "mental disorder" can be defined in terms of necessary conditions that are jointly sufficient (1).