Harmful Dysfunction 1 Running head : HARMFUL DYSFUNCTION , MENTAL DISORDERS AND DISEASE The Harmful Dysfunction Analysis and the Differentiation Between Mental Disorder and Disease

Wakefield’s Harmful Dysfunction Analysis (HDA) for distinguishing disorders from nondisorders has received much attention in the literature. Although the analysis has many strengths, Wakefield (1999a; 1999b) fails to appropriately capture the nature of the disorder construct thereby leading to much confusion. A solution is offered suggesting disorder can be thought of as a utilitarian construct. When viewed in this light, the HDA offers an excellent and useful definition of disease for medicine. However, the HDA fails as a useful definition for mental disorders because it contains a greedily reductionistic error that suggests all mental disorders are reducible to biological theory. An alternative way of conceptualizing mental disorders is offered and it is suggested that the HDA’s success in defining disease provides an important piece that allows mental health scientists begin to answer which mental disorders are akin to medical diseases and which mental disorders are not. keywords: psychiatry, psychopathology, evolution, illness, natural selection, essentialist concept Harmful Dysfunction 3 The Harmful Dysfunction Analysis and the Differentiation Between Mental Disorder and Disease The debate over what constitutes a legitimate definition of mental disorder has raged since the earliest days of psychology and psychiatry. Most in psychology and psychiatry are aware of the challenges to the entire notion of mental illness offered by Szasz (1974) and the heated debates regarding the classification of homosexuality several decades ago. Conflicting opinions about whether or not phenomena such as premenstrual dysphoria (Ginsburg & Carter, 1987), anti-social behavioral tendencies (Koski & Mangold, 1993), and binge eating (Hetherington, 1993) should be classified as disordered continue today. The debates about the nature of mental disorders have been fierce because the concept is such an important one. Whether or not a condition or individual is disordered carries a host of socio-political implications, such as health care treatment and assistance, social control, stigmatization, media attention, and the dispersal of resources for research. Over the past decade, Jerome C. Wakefield has emerged as a key voice in this arena with his proposal for explaining the disorder concept, called the Harmful Dysfunction Analysis ([HDA]; 1992a, 1992b, 1997a, 1999a, 1999b). The HDA proposes that the concept of disorder consists of two equally important components, a socially determined harm and a scientifically determined dysfunction of an internal mechanism, whereby dysfunction is defined in terms of the mechanism failing to perform its naturally selected function. Because of its inclusion of both components, the HDA can be considered a hybrid that combines previously offered biologically scientific approaches (e.g., Kendall, 1975; Scadding, 1990) with previously offered social value approaches (e.g., Sedgwick, 1982). In short, Wakefield’s analysis has generated an AND out of an historical OR. Harmful Dysfunction 4 The HDA has drawn a substantial amount of attention and recently (1999) a special issue of the Journal of Abnormal Psychology was devoted to examining the concept. Both supporters and critics in the special issue generally agreed that Wakefield’s combination of scientific judgment with social value was a strong move forward. A second strength of the HDA is that it clearly anchors the concept of disorder to scientific investigations. Third, Wakefield (1992a, 1999a) effectively articulates that evolutionary analyses are crucial to analyses of biological function and dysfunction and that, in many instances, we can distinguish ordered from disordered biological functioning. Finally, Wakefield demonstrates that many, if not all, disorder attributions in medical domains other than psychiatry strongly coincide with notions of dysfunction derived either explicitly or implicitly from evolutionary theory. For example, a heart attack is an example of a dysfunction because the heart was fashioned via evolutionary processes to circulate blood throughout the body. Broken bones, cancers, and strokes are also clear examples of harmful dysfunctions readily identified by the HDA. Being shorter than average, fevers in response to infection, wrinkles due to aging, and pain from a broken bone are not dysfunctions, as these occurrences do not involve breakdowns of evolved mechanisms. Taken together, these positives point to Wakefield’s framework being a significant and important advance over previous definitions of disorder or disease. Despite these advantages, there are two major problems with the HDA in its current form. First, although Wakefield should be commended for recognizing that socially constructed values and scientific judgments both make up the concept of disorder, I argue that his hybridization of the two components has ultimately been unsuccessful and that Wakefield fails to appropriately capture the nature of the disorder construct. Because of this failure, much confusion results regarding what the HDA is purporting to explain. In contrast to Wakefield, I Harmful Dysfunction 5 argue that neither disorder nor dysfunction are “essentialistic concepts,” that the HDA is not falsifiable in its current form, and that Wakefield confusingly vacillates between arguing that the HDA is a prescription for how disorder should be defined and a description of how people define what is and is not disordered. I offer a potential solution to this problem by suggesting that the concepts of disorder and dysfunction are utilitarian constructs that arise out of the applied side nature of the health sciences. The second major problem with the HDA is that it only provides a framework for defining and identifying biological disorders. For Wakefield, psychological disorders are of the same natural kind as biological disorders and both are adequately captured by the HDA. I argue this is a fundamental conceptual error. Psychology is no more fully reducible to biological theory than biology is fully reducible to chemical theory. As such, a definition of mental disorder that only captures biological dysfunctions is inadequate and misses an entire class of conditions, namely diagnosable mental disorders that are psychological in nature and that cannot be reduced to biological dysfunctions. Thus, whereas Wakefield (1992a, 1999a) equates disorder with disease, I argue for a differentiation between those mental disorders that result from broken biology (i.e., mental diseases) and those mental disorders that do not. This perspective offers a potentially powerful new way for conceptualizing mental disorders in general and may provide the beginning of a solution for how to define and differentiate psychiatric and psychological disorders. Before exploring these issues, however, we must turn our attention to the nature of the disorder construct. The Nature of the Disorder Construct Dysfunction is Not an Essentialistic Concept Harmful Dysfunction 6 Wakefield adopts a classical view of the disorder concept, summing up his position in his concluding paragraph in the JAB special issue: “Natural function refers to naturally selected effects, a concept well anchored in scientific theory, so dysfunction and disorder also refer to real phenomena. ” (Wakefield, 1999b, p. 472). In concluding his target article, Wakefield (1999a) spelled out his claim that dysfunction is an essentialistic concept: Concept theorists sometimes speak of underlying, theoretical-explanatory causal processes that unite a category as essences, and concepts defined in terms of such essential processes as essentialist concepts. The HD analysis claims that natural selection underlies natural functions and thus is crucial to attributions of dysfunction, as well; to this extent disorder is an essentialist construct. (However, disorder is not a purely essentialistic concept due to the harm component). (p. 397) Wakefield is arguing that because evolutionary functionalism is an essentialist concept, then the dysfunction of evolved mechanisms must also be an essentialist concept. However, careful examination reveals this assertion to be problematic. The reason this assertion is problematic is because the underlying causal structure of natural functions is different than the causal structure underlying the dysfunctions of those mechanisms. As I am sure Wakefield would agree, evolution through natural selection is a theory about the causal process that underlies biological organization, but it is not a theory about the infinite variety of causal processes that result in the breakdown of that organization. In fact, Wakefield (1999c) makes just this point in a recent article: The theory of normal heart function and the account of heart disorders have very different logical structures because the domains of data have very different intrinsic properties. In the domain of normal functions, many diverse features are Harmful Dysfunction 7 likely to be understandable in terms of one elegant functional theory based on evolutionary design; in the domain of dysfunctions, each type of failure may become the subject of a theory, or many theories, all on its own. [italics added] (p. 970) Thus, many diverse phenomena cause the dysfunctions of evolved mechanisms. This is important because, as Wakefield states, essentialistic concepts are labels for categories that are linked by underlying causal processes. Yet, breakdowns in evolved functional design are not essentialistic concepts as there is clearly not a global underlying causal process that accounts for or unites this set of conditions. Instead, dysfunctions, as defined by Wakefield, are merely linked to an essentialistic concept, natural function. Linking a construct to an essentialist concept and “discovering” an essentialist concept are two fundamentally different things. If dysfunction is not an essentialistic concept, then can disorder be considered an essentialistic