Considering Diagnosis for "Sick" Relationships
By Shankar Vedantam
Washington Post Staff Writer
Sunday, September 1, 2002; Page A01
of the nation's top psychiatrists are advocating the creation
of an entirely new category of mental illness that could profoundly
alter the practice of psychiatry and result in tens of thousands
of families being diagnosed with a psychiatric disorder.
a monograph being circulated by the American Psychiatric Association
(APA), the doctors recommend that a category called "Relational
Disorders" be added to the next edition of the Diagnostic
and Statistical Manual (DSM), which is the psychiatric profession's
official guide for defining emotional and mental illnesses.
every psychiatric diagnosis so far, this new type of disorder
would identify sickness in groups of individuals and in the relationships
between them. This is a profound conceptual shift from the medical
model of psychiatry, in which illnesses are diagnosed solely in
the proposed class of illness, an individual might be diagnosed
as healthy except when it comes to certain relationships. For
the moment, the new category of mental illness would apply only
to family relationships. If the new category is created, couples
who constantly quarrel and parents and children who clash could
be diagnosed with mental illness and treated, possibly with drugs.
Troubled relationships between siblings could be the next large
hope that creating a new disease category would encourage systematic
study, drug trials and insurance coverage.
move, however, is already provoking controversy and opposition
inside and outside psychiatry, as doctors and society grapple
with whether such troubled relationships are social problems or
have long been interested in such relationships, because they
often lead to marital and child abuse as well as depression. But
so far, doctors have not sought to label the relationships, themselves,
psychiatrists calling for the creation of a "Relational Disorders"
category are led by Michael First of Columbia University, editor
of the previous edition of the psychiatry manual, and David Reiss
of George Washington University. They and others say that troubled
relationships are the reason many people seek psychiatric help
and that improving those relationships can lift people out of
depression, improve cardiac and immune system functioning and
even heal wounds faster.
and Weiss face major hurdles. Several psychiatrists oppose the
move, portending a clash that could last for months or years --
doctors are still in the early planning stages for the next edition
of the manual. Some worry that the new category of disorders would
fuel fears that psychiatrists are inventing disorders as a backdoor
way to fix social problems.
talk of the new category was begun by First at a recent meeting
of the APA in Philadelphia, the psychiatrist said that troubled
family relationships were his only targets for treatment. But
other doctors warned that the category could be quickly expanded.
What about troubled relationships between managers and employees,
or even troubled relationships between individuals and the state?
One psychiatrist at another session dubbed terrorism an example
not of individual pathology, but of "social pathology."
can take road rage as a relational disorder. It's a relationship
between the person and traffic," said Bedirhan Ustun, a doctor
with the World Health Organization. Robert Spitzer, a previous
editor of the manual, said the new category would give fresh ammunition
to critics of psychiatry, such as the Church of Scientology.
are Scientologists on the street making fun of our diagnoses,"
he told First, referring to critics outside the meeting halls
who spun a roulette wheel to offer passersby a psychiatric diagnosis.
"It's one thing to call something a problem. But to call
it a disorder is to move away from the medical model."
medical model is the direction Spitzer and other psychiatrists
took more than a quarter-century ago to move their field from
Freudian insight and analysis toward a classification similar
to other medical specialties, with mental illnesses linked to
brain disorders. Although some aspects of treatment under the
medical model include the use of talk therapy techniques, the
major thrust of modern psychiatric research and practice has been
medicines such as Prozac that change brain chemistry.
disorders could upset the medical model by diagnosing relationships,
instead of individuals or individual brain chemistry, as sick.
First and Reiss argue that whether the new classification fits
the model is less important than whether it can help people.
in Dr. Spitzer's generation are very concerned that all the other
branches of medicine are going to laugh at us," Reiss said.
"That's not an issue anymore in psychiatry. Everybody understands
that we treat real disorders and we know how to diagnose and treat
them. One mark of our maturity is that we're going to recognize
the disorders as they appear clinically, and we are not going
to worry about whether some conservative view of the medical model
will make us a laughingstock or not."
marital and child abuse has long required that clinicians look
at relationships, Reiss and First said in interviews. Spouses
who violently clash with each other can divorce and go on to have
perfectly normal relationships with other people. Similarly, a
parent may have a normal relationship with one child but an abusive
relationship with another.
you look at a person in isolation, you see nothing -- something
only happens in the interaction," First said. "That
makes the disorder in the relationship. . . . It's the way two
people interact that creates the fire, the explosion."
therapists have always worked on relationships to help individuals
with psychiatric diagnoses.
of us believe the effects go both ways," said Steven Beach,
a psychologist at the University of Georgia and an expert on marital
discord and therapy. "If you are depressed, it creates a
strain on relationships, and if you are having a lot of difficulties
in relationships, it places a strain on you personally and increases
cited a study that showed that improving couples' relationships
was just as effective as treating individuals; both techniques
lifted people out of depression.
for Spitzer's concern about moving psychiatry away from the medical
model, Beach said that most family therapy experts he knew "would
cheer if we could de-medicalize the DSM. Psychologists [who are
not medical doctors] often think the disorders have been too medicalized."
said that he believed there were "genetic underpinnings"
to relationship troubles and that if the new category was created,
doctors would find that "they are every bit as medical as
everything in the DSM."
remain unconvinced. Steven E. Hyman, former director of the National
Institute of Mental Health and now provost at Harvard University,
said relational disorders should not be included in the psychiatry
better way to think about child and spouse abuse -- if they should
be medicalized at all, and that is an open question -- is to recognize
that the expression of psychiatric symptoms can be context dependent,"
he wrote in an e-mail from Australia. Some psychiatric symptoms
can be elicited by outside cues -- including other people -- much
like people with allergies sneeze in the presence of pollen, he
to find the neural and genetic underpinnings of relationship problems
to make the category fit the medical model of psychiatry is misguided,
added Paul McHugh, former chairman of psychiatry at Johns Hopkins
can't reduce everything to the idea that there is a brain flaw
in every troubled situation," he said. "Perfectly normal
people make mistakes in arithmetic. You don't look for problems
in their brains, you look for problems in their arithmetic."