Draft:Harmful Dysfunction Analysis
Harmful Dysfunction Analysis
Harmful dysfunction analysis (HDA) is a theoretical framework developed by American philosopher and clinical social worker Jerome C. Wakefield to define mental disorder. Bringing together evolutionary theory, philosophy, and clinical practice, Wakefield proposes that mental disorder is best thought of as a “harmful dysfunction”. Specifically, HDA suggests that a condition is a mental disorder only if it results from the failure of an internal mechanism to perform its natural evolutionary purpose (dysfunction) and results in effects considered harmful within a particular society (harm).
Background and Critique of Existing Models
Wakefield developed HDA in response to what he saw as persistent confusion in how psychiatry defines mental disorder. He was critical of the DSM-III-R, which described mental disorder as “statistically unexpectable distress or disability.” Although intended to improve diagnostic consistency across clinicians, Wakefield argued that the definition failed to meaningfully distinguish disorders from non-disorders and lacked a solid grounding in biological theory.[1]
Historically, diagnostic approaches in psychiatry have often followed two broad traditions. The earlier approach was to base diagnosis on social deviance. Traits and behaviours deemed unacceptable, such as dissenting political views or minority sexual orientations, would be pathologized not because they reflected any underlying dysfunction, but simply because they were socially disapproved. Wakefield criticised this approach for its failure to differentiate mental disorder from behaviours that simply go against social expectations.[2]
Another approach was to avoid cultural bias by defining mental disorder in terms of statistical deviation. Conditions were classified as disordered if they fell significantly outside the average range of psychological measures. This is reflected in past diagnostic criteria for intellectual disability, which relied on low IQ scores, and in frameworks like Christopher Boorse’s biostatistical theory.[3][4] Although this method appears more objective, Wakefield argued that it wrongly equates statistical rarity with disorder. As he explains, “excellence in strength, intelligence, energy, talent, or any other area is just as statistically deviant as its opposite.”[5] Conversely, many conditions like the common cold are recognised as disorders despite their prevalence. A condition's frequency alone, he maintained, cannot reliably determine if it is a disorder.
HDA sought to correct these issues by requiring both dysfunction and harm.
Theoretical Components
Defining Harm
“‘Harmful’ is a value term, referring to conditions judged negative by sociocultural standards.”[6]
In the context of HDA, harm refers to negative consequences experienced as a direct result of dysfunction. Importantly, whether something is considered harmful depends on the person's cultural environment.
Wakefield originally proposed that ‘harm’ be interpreted broadly, encompassing any condition viewed negatively within a particular culture.[7] More recently, he has clarified that for a condition to count as harmful, the negative consequences must be directly caused by the dysfunction. As a result, social stigma is an insufficient basis for harm.[8]
Defining Dysfunction
“A failure of some internal mechanism to perform a function for which it was biologically designed.”[9]
Dysfunction in HDA refers to a system's inability to serve the purpose it evolved for. This idea draws on natural selection, which explains that the traits present in living organisms emerged because they contributed to the organism's survival and reproductive success. Wakefield considers dysfunction the factual, scientific aspect of mental disorder.
Disorder as a Hybrid Concept

HDA holds that both harm and dysfunction must be present for a condition to be a mental disorder. Dysfunction provides the objective basis for diagnosis; harm adds cultural sensitivity. As a result, not all dysfunctions are mental disorders, and not every harmful condition is a mental disorder.
An example Wakefield uses to prove this is dyslexia.[10] Essentially, dyslexia is a failure of the brain's language-processing system and therefore counts as a dysfunction. However, whether it is considered a mental disorder depends on the cultural context. In a literate society, where reading is indispensable to daily life, dyslexia leads to clear disadvantages, making it a disorder. In a pre-literate society where reading is not a necessary skill, it would cause no harm and not be viewed as a disorder. Wakefield describes such cases as “harmless dysfunctions": biological failures that do not produce socially meaningful problems.[11] Wakefield also highlights other conditions like criminality and illiteracy, which are harmful but do not stem from dysfunction.[12] This illustrates that harm alone is insufficient.
Criticisms
On Dysfunction
Critics of the dysfunction requirement argue that it is often difficult, if not impossible, to identify the evolved function of complex mental mechanisms.[13][14] Many mental functions may have arisen as by-products of other adaptations or evolved to serve multiple purposes, making it challenging to pinpoint a clearly ‘designed’ function.
Philosopher Maël Lemoine questioned whether the dysfunction component is genuinely value-free, suggesting it inherently involves interpretive assumptions, not just description.[15] Further, Justin Garson points to developmental plasticity, the capacity to develop different traits in response to early environments, as a challenge to the dysfunction requirement of HDA. He argues that this adaptability can lead to "mismatches", where traits that were once beneficial in childhood become harmful later in life. These cases, he suggests, result in genuine mental disorders without technically involving dysfunctions.[16]
On Harm
The harm component has also attracted criticism, particularly regarding its reliance on social values. Rachel Cooper has argued that while the harm concept is necessary to prevent the medicalisation of oddities, it remains vague. She finds Wakefield's definition broad and that the concept needs further clarification.[17]
Furthermore, Andreas De Block and Jonathan Sholl question whether harm should be determined through social values or individual experience. They argue that both approaches present problems. If harm depends on local social norms, the concept becomes vulnerable to culturally biased conclusions. For example, it could justify labelling homosexuality a disorder in heteronormative societies if it is also assumed to involve dysfunction. Alternatively, if harm is based on an individual's subjective experience, HDA would encourage diagnostic inconsistencies, as some individuals with severe disorders may not perceive themselves as harmed. In either case, they conclude that the harm requirement introduces enough subjectivity to undermine HDA's goal of offering a coherent definition of mental disorder. Additionally, they argue that Wakefield "smuggles" the harm component into his account of dysfunction, implicitly using harm to decide whether dysfunction is present. As a result, the two concepts do not seem truly independent as Wakefield suggests.[18]
Alternative Models
Notably, Christopher Boorse continues to defend his biostatistical theory of mental disorder. Boorse argues his model avoids the ambiguities associated with cultural judgements.[19] He also contends that HDA conflicts with actual medical practice, particularly in its treatment of so-called ‘harmless dysfunctions’. He notes that many such conditions are nonetheless recognised as disorders in clinical settings, raising concerns about HDA’s legitimacy.[20] Lemoine has also proposed a 'Harmful Abnormality Analysis' as an alternative.[21]
References
- ^ Wakefield, Jerome C. (1992). "Disorder as harmful dysfunction: A conceptual critique of DSM-III-R's definition of mental disorder". Psychological Review. 99 (2): 232–247. doi:10.1037/0033-295X.99.2.232. ISSN 1939-1471.
- ^ Wakefield, Jerome C. (1992). "The concept of mental disorder: On the boundary between biological facts and social values". American Psychologist. 47 (3): 373–388. doi:10.1037/0003-066X.47.3.373. ISSN 1935-990X.
- ^ Boat, Thomas F.; Wu, Joel T.; Disorders, Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental; Populations, Board on the Health of Select; Board on Children, Youth; Medicine, Institute of; Education, Division of Behavioral and Social Sciences and; The National Academies of Sciences, Engineering (2015-10-28), "Clinical Characteristics of Intellectual Disabilities", Mental Disorders and Disabilities Among Low-Income Children, National Academies Press (US), retrieved 2025-04-17
- ^ Boorse, Christopher (1977). "Health as a Theoretical Concept". Philosophy of Science. 44 (4): 542–573. ISSN 0031-8248.
- ^ Wakefield, Jerome C. (1992). "The concept of mental disorder: On the boundary between biological facts and social values". American Psychologist. 47 (3): 373–388. doi:10.1037/0003-066X.47.3.373. ISSN 1935-990X.
- ^ Wakefield, Jerome C. (2007). "The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis". World psychiatry: official journal of the World Psychiatric Association (WPA). 6 (3): 149–156. ISSN 1723-8617. PMC 2174594. PMID 18188432.
- ^ Wakefield, Jerome C. (2007). "The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis". World psychiatry: official journal of the World Psychiatric Association (WPA). 6 (3): 149–156. ISSN 1723-8617. PMC 2174594. PMID 18188432.
- ^ Wakefield, Jerome C.; Conrad, Jordan A. (2022), Neesham, Cristina; Reihlen, Markus; Schoeneborn, Dennis (eds.), "The Harmful Dysfunction Analysis of Mental Disorder: Implications for the Social Sciences and Management Practice", Handbook of Philosophy of Management, Cham: Springer International Publishing, pp. 309–332, doi:10.1007/978-3-030-76606-1_44, ISBN 978-3-030-76606-1, retrieved 2025-04-17
- ^ Wakefield, Jerome C. (2007). "The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis". World psychiatry: official journal of the World Psychiatric Association (WPA). 6 (3): 149–156. ISSN 1723-8617. PMC 2174594. PMID 18188432.
- ^ Wakefield, Jerome (2021-02-16). "Can the Harmful Dysfunction Analysis Distinguish Problematic Normal Variation from Disorder? Reply to Andreas De Block and Jonathan Sholl". MIT Press. doi:10.7551/mitpress/9949.003.0032.
- ^ Wakefield, Jerome C. (2014-12-01). "The Biostatistical Theory Versus the Harmful Dysfunction Analysis, Part 1: Is Part-Dysfunction a Sufficient Condition for Medical Disorder?". The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine. 39 (6): 648–682. doi:10.1093/jmp/jhu038. ISSN 0360-5310.
- ^ Wakefield, Jerome C. (2007). "The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis". World psychiatry: official journal of the World Psychiatric Association (WPA). 6 (3): 149–156. ISSN 1723-8617. PMC 2174594. PMID 18188432.
- ^ McNally, Richard J (2001-03-01). "On Wakefield's harmful dysfunction analysis of mental disorder". Behaviour Research and Therapy. 39 (3): 309–314. doi:10.1016/S0005-7967(00)00068-1. ISSN 0005-7967.
- ^ Aftab, Awais; and Rashed, Mohammed Abouelleil (2021-07-04). "Mental disorder and social deviance". International Review of Psychiatry. 33 (5): 478–485. doi:10.1080/09540261.2020.1815666. ISSN 0954-0261. PMID 33016793.
- ^ Lemoine, Maël (2021-02-16). "Is the Dysfunction Component of the "Harmful Dysfunction Analysis" Stipulative?". MIT Press. doi:10.7551/mitpress/9949.003.0016.
- ^ Garson, Justin (2021-02-16). "The Developmental Plasticity Challenge to Wakefield's View". MIT Press. doi:10.7551/mitpress/9949.003.0021.
- ^ Cooper, Rachel (2021-02-16). "On Harm". MIT Press. doi:10.7551/mitpress/9949.003.0033.
- ^ De Block, Andreas; Sholl, Jonathan (2021-02-16). "Harmless Dysfunctions and the Problem of Normal Variation". MIT Press. doi:10.7551/mitpress/9949.003.0031.
- ^ Boorse, Christopher (1997), Humber, James M.; Almeder, Robert F. (eds.), "A Rebuttal on Health", What Is Disease?, Totowa, NJ: Humana Press, pp. 1–134, doi:10.1007/978-1-59259-451-1_1, ISBN 978-1-59259-451-1, retrieved 2025-04-17
- ^ Boorse, Christopher (2024-08-01). "Wakefield's Harm-Based Critique of the Biostatistical Theory". The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine. 49 (4): 367–388. doi:10.1093/jmp/jhae017. ISSN 0360-5310.
- ^ Lemoine, Maël (2021-02-16). "Is the Dysfunction Component of the "Harmful Dysfunction Analysis" Stipulative?". MIT Press. doi:10.7551/mitpress/9949.003.0016.