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Two preprints published advancing Wakefield's 'Harmful Dysfunction' analysis of mental disorder

I have posted two preprints regarding Wakefield's famous 'Harmful Dysfunction' analysis of disorder, to respond to various criticisms raised against it and provide a more scientifically tractable and philosophically sound evolutionarily informed analysis of 'disorder', 'illness' etc. The first deals with the 'dysfunction' component, the second the 'value' component of how scientific explanation interacts with medical norms. Titles and abstracts below (click the title for the full preprint). These are two chapters of my PhD thesis.


 


Jerome Wakefield’s ‘Harmful Dysfunction Analysis’ (HDA) recognises biological and psychological disorder exists wherever two conditions are met: concurrent harm, a subjective value component, and dysfunction, an objective component related to the interruption of evolutionarily selected effects. This is arguably the leading definition of disorder, and is prominently referenced in evolutionary psychiatry, yet suffers various criticisms. These particularly concern the ‘dysfunction’ component, which is undermined by the indeterminacy of ancestral function and a range of complex counter-examples, particularly relating to mismatch, by-products and extremes of adaptive spectrums. To tackle these criticisms, I provide a definitional framework which allows clear pathways to dysfunction attribution in the cases problematic for Wakefield. The key move here is distinguishing biological objects with fitness, a fundamentally quantifiable variable, from the selective processes of function and dysfunction which lead to that fitness, which rely on qualitative descriptions, and are much harder to exactly specify and demarcate to the level of precision necessary for the HDA. I also note the importance of specifying framing environments and trait descriptions. The resulting framework solves various problems with Wakefield’s account and leads to a taxonomy of different classes of dysfunction. This is unique amongst existing evolutionary taxonomies of disorder by offering strict demarcation, exclusivity and greater theoretical completeness. By relying ultimately on fitness effects rather than descriptions of dysfunctional processes and recognising distinct possible classes of evolutionary dysfunction, a more tractable direction for scientific investigation into any trait’s dysfunctional status is offered, with the potential to make Wakefield’s HDA workable.


 


The definition of medical ‘disorder’ is a matter of longstanding debate. A leading account is Jerome Wakefield’s ‘harmful dysfunction’ analysis, a hybrid model which merges normative and naturalist elements to propose disorder exists in cases of concurrent harm (value-defined) and dysfunction (defined evolutionarily). Despite significant impact in academia, this has so far failed to affect mainstream medical treatment or discourse, with a major criticism being that this definition doesn’t correctly capture all conditions of medical relevance or actual medical ideals. This paper provides a supplementary structural nuance to better reflect how medical treatment and terminology incorporate naturalistic facts. I argue that Wakefield is right in utilising a hybrid model incorporating naturalism and normativity. However, in understanding how medicine is directed, making the normative and naturalistic equally necessary is problematic, because the imperatives of naturalism and normativity directly impede each other; norms seek to help those who need help, naturalism concentrates on objective facts, but neither can be fulfilled as a coherent goal of medical treatment when combined as equally necessary. Instead, I propose a hierarchical harmful dysfunction model better reflects current medical ideals, where normative values are necessary and sufficient conditions to prescribe treatment, whilst naturalistic knowledge plays a role informing those normative values. This accounts for the edge cases and practise of medicine not fully captured in Wakefield’s account of ‘disorder’.


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