Wakefield's hybrid account of mental disorder.
Authors: Bengt Brülde
Journal: World Psychiatry (2007)

Wakefield's question is what makes a  condition a  He formulates  question in two different ways: a) What do we mean when we say  a  condition is a medical  rather than, for instance, a  form of human suffering? and b) Which  conditions should be classified as pathological? The latter question is far more significant, especially if we concede  no consensus exists on  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,  notion of disease. The distinction between disease and injury has no practically important consequences, whereas  distinction between  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,  disorders are   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   or harmful according to social values to characterize  value component, but to say  a condition is deemed negative by sociocultural  is really a factual statement. Moreover, to refer to existing  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  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  Wakefield's analysis is, in fact, a proper hybrid account. In this case, his account of  value component is probably too narrow, and  same holds for his account of  factual component.

Mental disorders typically involve some kind of harm to  individual who has  disorder, e.g. distress or disability, and we rely rather heavily on considerations of harm when drawing  line between  and non-disorder. This strongly suggests   connection between  and harm is conceptual rather than contingent. Wakefield makes a stronger point than this, however, namely  harm to  individual is necessary for disorder, and  we need not rely on any other evaluative considerations to delineate  class of   However, it seems  there are  disorders  are classified as disorders in virtue of other evaluative considerations, e.g.,  paedophilia and antisocial personality  count as disorders because they are abnormal and/or  to others. This suggests  we should not draw  line between  and non-disorder on  basis of harm-forthe- individual-evaluations alone, but  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  disorder, however, and it is incompatible with  idea  mental disorder can be defined in terms of necessary conditions  are jointly sufficient (3). Wakefield's  account of  has been heavily criticized (1,4- 7). Most objections purport to show  dysfunction (in Wakefield's sense) is not necessary for disorder, i.e.  someone may well suffer from a  even when there is no evolutionary malfunction. Some of these objections try to establish  many  functions are not direct  adaptations, but rather adaptively neutral by-products of adaptations (4), and  some disorders involve failed mechanisms  have no adaptive function, like spandrels, exaptations, or vestigal parts.

Other arguments purport to establish  disorders can be caused by mechanisms  are working exactly as designed by evolution, e.g.,  some disorders are  adaptive reactions to pathogenic inputs. Injuries due to external trauma involve dysfunctions, however, and so do inflammatory reactions, infectious diseases, and posttraumatic stress  But consider   vs. pathological bereavement (a possible component in depressive disorder) as two possible reactions to loss. Is  difference between these conditions really  some specific  is malfunctioning in  second case but not in  first? To defend  dysfunction account by postulating a loss-response mechanism is rather farfetched. It seems more plausible to regard  two conditions as different ways of functioning, where the depressed way of grieving is far more  than  normal way. This suggests   presence of a dysfunction is not essential to  Moreover,  exclusion of  grief from  class of   can be questioned: for instance, it might be appropriate to regard grief as a  injury and, if all injuries are disorders, so is grief. It can also be argued  people in grief are entitled to sick leave with compensation. Normality is simply not  issue here.

To conclude, Wakefield's idea  disorders are dysfunctions (defined in  terms) tends to exclude too much from  category of   There are alternative views, but these views also suffer from certain weaknesses (1). This strongly suggests  we cannot save our linguistic intuitions unless we abandon  idea  mental disorder can be defined in terms of necessary conditions  are jointly sufficient (1).