A “paradigm shift” is under way, which is carrying the speciality beyond the medical model, with its emphasis on the diagnosis and treatment of dubious disease entities, towards an entirely new conceptual framework which defines the basic components of human nature in terms of their evolutionary origins and their essential developmental needs.
—Anthony Stevens and John Price, Evolutionary Psychiatry
The flaw in the DSM approaches to emotional disorders is fundamental: the DSM fails to distinguish protective responses from diseases.
—Randolph M. Nesse and Eric D. Jackson, Evolutionary Foundations for Psychiatric Diagnosis: Making DSM-V Valid
Jerome Wakefield and his colleagues have argued that mental disorder is “harmful dysfunction.” This account has two parts. It is claimed to be a matter of scientific fact that a system honed by evolution has in some persons become dysfunctional. And then values come in: the dysfunction has to be harmful.1 Harm will be discussed in Chapter 17. Here the question is whether psychiatric disorders should be seen in terms of dysfunctional systems.
The gene that causes sickle-cell anemia also protects against malaria. One approach to evolutionary psychiatry explains the survival of some psychiatric disorders in terms of their possible genetic links to traits that have survival value. It has been suggested, for example, that schizophrenia might have a genetic link to the development of language,2 or to the development of parts of the brain that underlie social relationships.3 Some of these conjectures may be right. But for now they are still speculative.
Other evolutionary models give explanations more closely tied to features of psychiatric disorders. Thoughts, feelings, or actions that are inappropriate to their context are taken to be signs that some chemical, physiological, or psychological system is not serving the function for which natural selection “designed” it. Hallucinations signal some fault in perceptual systems that evolved to give reliable information. The aim of correcting faulty systems justifies psychiatry as a branch of medicine.
How far do emotional and mood disorders fit this model? Are there emotional systems parallel to the cognitive ones? Darwin saw emotions as evolved from actions. They are the suppressed versions. Anger is suppressed physical aggression. Fear is the suppressed inclination to run away. Both fighting and flight can have survival value. So may the ability to suppress either of them. It is easy to see how the systems involved in Darwinian emotions might have evolved.
In particular, unpleasant emotions may, in parallel with physical pain, have evolved as defenses against threats or difficulties. On this view, feeling low after losing a job or being left by a partner is not pathology. The fundamental mistake is said to be treating protective responses as diseases.4 These normal “protective” responses are different from cases where, in evolutionary terms, something is going wrong. There are two main models used to account for the pathological cases. On the “mismatch” model, some psychiatric disorders come from parts of our nature that adapted to an early human environment that is no longer part of the world of today. On the “over-reaction” model, some psychiatric disorders are exaggerated versions of responses that are still adaptive.
There may be mismatches between our situation and our evolved human nature. We fear snakes but have no fear of cigarettes or of driving too fast. Some evolutionary psychiatrists see this mismatch in phobias and anxiety disorders. Once it may have been adaptive for some people to have stronger than average fears or anxieties. But these dispositions are no longer useful. Where they are also distressing or incapacitating, they are plausible candidates for treatment.5
The mismatch model faces questions about the supposed early environment when our nature was formed. John Bowlby coined the phrase “the environment of evolutionary adaptedness.” But there might not have been one single environment. The view that the central characteristics of human nature were fixed in some early period, perhaps the Pleistocene, is too simple. Human evolution has continued, with varying adaptations in different cultural environments.6
Tracy Thompson saw that some of her responses when she was depressed had been inappropriate. Her boyfriend suggested changing their weekend plans. This “sent me catapulting into hysteria, it was proof that Sam did not love me. I sobbed for hours.” Sometimes it was anger: “Any minor inconvenience could set me off—misplacing a blouse, getting lost somewhere, missing a phone call from Sam, finding myself stalled in a traffic jam … I threw things; I beat helplessly on the floor with my hairbrush; I scratched and tore at my own skin. The provocations were always so minor that I had usually forgotten them by the next day; sometimes I would look at a bruise on my arm and think: What was that for?”7
What makes emotional responses inappropriate? Sometimes they reflect distorted interpretations. Usually they are disproportionate. Later Tracy Thompson saw hours of sobbing as an over-reaction to changed plans for the weekend.
Some psychiatric disorders may be exaggerated versions of responses that are otherwise still adaptive. Panic helps people escape from danger; panic disorder is panic without the danger. Suspicion helps people avoid survival-threatening traps. Low-key mood favors caution, avoiding the risks taken in a more euphoric state. Paranoia and clinical depression can each be seen as exaggerations of these adaptive traits, perhaps a failure in a system whose function is to regulate them.
The over-reaction model needs more clarity about the adaptive value of such traits as low mood. As well as the tendency to support caution, there are other suggestions about its adaptive value. Being depressed may be a way of signaling a need for help. Some have seen depression as a prompt to accept defeat in competition and to adjust to the resulting low rank. Some or all of these accounts may be right. It is not clear how we should decide. Critics of evolutionary psychology have asked the “just-so story” question: How do we tell evidence from plausible but ad hoc speculation?
The mismatch and over-reaction models pull in opposite directions. Perhaps each fits different disorders. How should we rate adaptive against maladaptive aspects of an emotional state? Gloomy and suspicious people may be cautious in a way that helps them survive. But how is this to be weighed against the fact that their gloom and suspicion can put other people off ? How can we tell which traits are adaptive and which are not?
Richard Wollheim’s horror of newsprint was a problem for friends when they had him over for a meal. “Every scrap of newspaper had to be either thrown away or thoroughly concealed (not just tucked away findably under a cushion): the mere sight of newsprint would make it impossible for him to eat his dinner.”8 In his autobiography Wollheim courageously called his disgust at the smell of newsprint “the most persistent thread in my life, stronger, more unchanging, than any taste or interest, more demanding than any intellectual challenge.” He went on to say, “I have never seen any way in which the power of love could transform it. It was like a ghost in the house that could be expelled only by demolishing the house.”9
Richard Wollheim could see that his horror was out of proportion. An Oxford colleague poured glasses of sherry for Wollheim and himself. Wollheim was overcome with nausea. The washed cupboard had been lined with newspaper. The rims of the upside-down glasses had touched the wet paper. His host washed the glass and gave him more sherry. This was not enough, as the other glass still smelled of wet newspaper. At first the response seems totally out of proportion. How can someone be so upset by wet newspaper? But this may be too hasty. Some judgments about appropriateness need complex interpretation.
Wollheim traced his revulsion to an early childhood event. He and his brother were with their nanny, who was reading a newspaper account of a royal death. His brother resented Richard being nearer the nanny. He did not want her to pin the paper on the wall for them to see. So he made pellets from the paper, wet them in his mouth, and flicked them at the page she was reading. “The juices that had risen up into my mouth in sheer horror at the scene seemed to duplicate the taste of the little pellets in my brother’s mouth.” Wollheim saw the page of newspaper slipping out of the nanny’s hands onto the floor “like a great injured bird.” As it fell, the dead Queen’s picture was changed: her face, the emeralds, and the satin buttons “were now desecrated by spit, and smell, and the signs of disease.”10
There is always a question about whether to accept a Freudian claim linking a childhood episode to an adult problem. First-person accounts are not infallible, but they have a degree of authority, particularly when so vivid. Wollheim’s account is as claustrophobic as a Freudian case written up by Proust would be. And the causal link is given some support by the specific recurrence of wet newsprint.
If Wollheim’s account is right, the revulsion seems more intelligible. But is it proportionate? Proportionate to what? At one level it is still an extreme reaction to sherry glasses’ having touched wet newspaper. Wollheim himself saw this and tried unsuccessfully to eliminate it. But if it is a response to the residue of a childhood trauma, it is harder to say what is proportionate.
One concern about the “dysfunction” approach is that it could allow homosexuality to again be seen as a disorder. It is hard to avoid the view that the likely main evolutionary value of sexual desires is procreation. It is all too easy to see how the dysfunction view could be seized on.
Other doubts are conceptual and empirical. It can be hard to identify even cognitive systems and their functions. Where a feature of a species has lasted in the evolutionary struggle, it is likely to have contributed to gene survival or else be linked to other features that did. But evolution might not have honed it for a single function. This is obvious with large, complex features. Having a brain clearly contributes to survival, but it does so through many different functions. The brain is a hierarchy of systems: perceptual, cognitive, and so on. In turn perception is a hierarchy of systems: visual, auditory, and so on. And vision is a hierarchy of systems for recognizing color, shape, and such. The subdivision continues downward. It makes more sense to talk about the function of a system lower down than it does for a system higher up.
It is even more difficult to identify emotional systems and their evolutionary functions. There is the just-so-story question again. Maps of neurochemical pathways involved in emotions are starting to be unraveled. But now it is still optimistic to talk of clear emotional systems, each with an evolutionary function. Even the clusters of neurotransmitters, neural pathways, and so on that might make up an emotional “system” could serve many functions. This makes identifying emotional “dysfunction” problematic.
What is the evolved system that, functioning properly, might have kept Wollheim’s revulsion within bounds? Revulsion against smells might have evolved to keep us away from poisonous plants, decaying meat, or dangerous animals. But must there be a faulty system when people dislike the harmless smell of cabbage being boiled? Is there a system to control reactions to childhood trauma?
These problems are not decisive against the “dysfunctional system” view. A functional system might exist even if we cannot say what it is. But it does not follow that all inappropriate emotional responses indicate a system failure. In Wollheim’s case, we cannot identify a malfunctioning system, so we do not know whether there is one or not.
When is an inappropriate emotional response a sign of psychiatric disorder? The answer does not depend on speculating about systems. Whether a psychological condition impairs the good life is independent of what its causes are.
To call something a disorder or disability does not settle the issue of whether it should be treated. The treatment may be too painful or too expensive to be worthwhile. Or the disability may avoid something more dangerous, like wartime conscription into an army. Respect for autonomy is crucial. Under normal conditions a competent person has a right to refuse even beneficial treatment.
The person’s relation to a disorder or disability can be a reason for not treating it. There are (disputed) reasons for thinking blindness is not just a difference but a disability. But even if this is right, curing blindness can still make things worse. One blind man, “S.B.,” was cheerful, confident, and proud of his work as a carpenter and cobbler. After being given sight, he thought things looked drab and dull. Having changed from a blind man who coped well into a sighted man who coped poorly, he lost his self-respect. He died in the second year after the operation. Others given sight made the transition more successfully. But the case of S.B. suggests that treating a disability is not always the right thing to do.11
Despite these reasons for not always treating disorders or disabilities, disorder is still linked with treatment. If someone has a disorder, then, other things equal (which they may not be), it calls for the offer of treatment. The dysfunction may indicate the kind of treatment needed. But what calls for treatment is the harm: the way the condition makes someone’s life worse. In the case of psychiatric treatment, it is a psychological condition that makes someone’s life worse. Harm has priority. Whether or not a socially paralyzing horror of newsprint counts as a disorder depends, not on a conjectured mechanism going wrong, but on the kind and degree of harm it causes.