Harmful dysfunction and the search for value neutrality in the definition of mental disorder: response to Wakefield, part 2

The merit of sociological accounts of disorder: The Attention-Deficit Hyperactivity Disorder case

This article argues in favor of a sociological perspective on health and illness, drawing on recognized positions from the philosophy of health and illness about how to demarcate disorder from non-disorder. The argument specifies that a normative context in which bodies or behaviors are disvalued is a necessary component for identifying what constitutes a disorder, as this normative context allows material differences to be understood as dysfunctional and pathological. Descriptions of material states in themselves are insufficient to distinguish what is legitimately a disorder; some evaluative stance toward those states is also required. This article applies the argument to disorders of inattention and hyperactivity, currently best known as Attention-Deficit Hyperactivity Disorder. These disorders have been controversial since their formalization in the 1970s, the same time that they began receiving sociological attention. Sociological analyses have consistently expressed ambivalence toward recognizing claims about the biological status of such disorders. This ambivalence has at times committed to a problematic relationship between sociological explanation and medical explanation, implicitly allocating sociological explanation to an auxiliary position. This article argues that this is not necessary, as sociological perspectives address disorders on a fundamental, rather than secondary, register. Disorders are only intelligible due to the normative and social context in which they are found, and so medical sociology can recognize the validity of biological claims about disorders, such as Attention-Deficit Hyperactivity Disorder, while still asserting the essential social nature of disorder.

Hebephilia as mental disorder? A historical, cross-cultural, sociological, cross-species, non-clinical empirical, and evolutionary review

Blanchard et al. (2009) demonstrated that hebephilia is a genuine sexual preference, but then proposed, without argument or evidence, that it should be designated as a mental disorder in the DSM-5. A series of Letters-to-the-Editor criticized this proposal as a non sequitur. Blanchard (2009), in rebuttal, reaffirmed his position, but without adequately addressing some central criticisms. In this article, we examine hebephilia-as-disorder in full detail. Unlike Blanchard et al., we discuss definitions of mental disorder, examine extensive evidence from a broad range of sources, and consider alternative (i.e., non-pathological) explanations for hebephilia. We employed Wakefield's (1992b) harmful dysfunction approach to disorder, which holds that a condition only counts as a disorder when it is a failure of a naturally selected mechanism to function as designed, which is harmful to the individual in the current environment. We also considered a harmful-for-others approach to disorder (Brülde, 2007). Examination of historical, cross-cultural, sociological, cross-species, non-clinical empirical, and evolutionary evidence and perspectives indicated that hebephilic interest is an evolved capacity and hebephilic preference an expectable distributional variant, both of which were adaptively neutral or functional, not dysfunctional, in earlier human environments. Hebephilia's conflict with modern society makes it an evolutionary mismatch, not a genuine disorder. Though it should not be classified as a disorder, it could be entered in the DSM's V-code [corrected] section, used for non-disordered conditions that create significant problems in present-day society.

The lay concept of conduct disorder: do nonprofessionals use syndromal symptoms or internal dysfunction to distinguish disorder from delinquency?

BACKGROUND

Conduct disorder (CD) must be distinguished from nondisordered delinquent behaviour to avoid false positives, especially when diagnosing youth from difficult environments. However, the nature of this distinction remains controversial. The DSM-IV observes that its own syndromal CD diagnostic criteria conflict with its definition of mental disorder, which requires that symptoms be considered a manifestation of internal dysfunction to warrant disorder diagnosis. Previous research indicates that professional judgments tend to be guided by the dysfunction requirement, not syndromal symptoms alone. However, there are almost no data on lay conceptualizations. Thus it remains unknown whether judgments about CD are anchored in a broadly shared understanding of mental disorder that provides a basis for professional-lay consensus.

OBJECTIVE

The present study tests which conception of CD, syndromal-symptoms or dysfunction-requirement, corresponds most closely to lay judgments of disorder or nondisorder and compares lay and professional judgments. We hypothesized that lay disorder judgments, like professional judgments, tend to presuppose the dysfunction requirement.

METHOD

Three lay samples (nonclinical social workers, nonpsychiatric nurses, and undergraduates) rated their agreement that youths described in clinical vignettes have a mental disorder. All vignettes satisfied DSM-IV CD diagnostic criteria. Vignettes were varied to present syndromal symptoms only, symptoms suggesting internal dysfunction, and symptoms resulting from reactions to negative circumstances, without dysfunction.

RESULTS

All lay samples attributed disorder more often to youths whose symptoms suggested internal dysfunction than to youths with similar symptoms but without a likely dysfunction.

CONCLUSIONS

The dysfunction requirement appears to reflect a widely shared lay and professional concept of disorder.

Sorting out the concept 'disorder'

Current debates concerning the concept of mental disorder involve many different philosophical issues. However, it is not always clear from these discussions how, or whether, these issues relate to one another, or in exactly what way they are important for the definition of disorder. This article aims to sort through some of the philosophical issues that arise in the current literature and provide a clarification of how these issues are related to one another and whether they are necessary for defining disorder. I argue that the main concern in defining disorder, namely demarcation, is obscured by a number of these other philosophical issues and that a focus on demarcation gives us a means of placing these other issues in a clarifying context.

The effect of social context on psychiatrists' judgments of adolescent antisocial behavior

BACKGROUND

The DSM assumes that mental disorders can be identified by the presence of specific co-occurring symptoms associated with certain duration and impaired functioning, independent of the social context in which symptoms occur. The validity of this assumption was tested using the judgments of experienced psychiatrists. We hypothesized that psychiatrists would judge an identical set of adolescent antisocial behaviors, meeting the DSM-IV diagnostic criteria for conduct disorder, as indicative of mental disorder or non-disordered problem-in-living, depending on the social context.

METHOD

A representative sample of 483 psychiatrists in the United States read one of three experimentally manipulated vignettes depicting adolescent antisocial behavior and responded to questions concerning its nature, prognosis, cause, and response to various treatments.

RESULTS

Results supported our hypothesis. Under some circumstances, a youth may exhibit behaviors that meet the DSM-IV diagnostic criteria for conduct disorder, but be judged by psychiatrists as not having a mental disorder. In addition, as predicted, psychiatrists reached different judgments about course, etiology, and treatment responsiveness when the identical behaviors occurred in different social contexts.

CONCLUSIONS

The findings illuminate weaknesses in the validity of classification systems based on behavioral criteria independent of their social context. Implications of findings are discussed.

Dysfunction as a factual component of disorder

The harmful dysfunction (HD) analysis holds that disorder, mental or physical, requires harm, a value criterion, and dysfunction, a factual criterion referring to failure of a mechanism to perform a naturally selected function. Houts' arguments that the HD analysis does not offer an adequate factual account of dysfunction are examined and shown to be invalid. For example, his claim that the HD analysis confuses function with purpose, a value concept, ignores the analysis'account of function in terms of the value-free notion of effect-explanation; and his argument that functions imply norms (e.g., what mechanisms are 'supposed to' do) falsely assumes that such norms are evaluative. The HD analysis of function is analogous in logical structure to the functional analyst's factual behavioral notion of function. Houts' value account of disorder is inconsistent with people's classificatory judgments, as his own examples demonstrate.