Relational disorders: Disease of the month? CrossCurrents Spring 2003
CrossCurrents
The Last Word
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Move over, folie à deux (a.k.a. Shared Psychotic Disorder); you've got company. The American Psychiatric Association (APA)
is setting a research agenda for a future DSM-V with a new category - "Relational Disorders." At first glance, it seems like
a good idea.
Most psychiatrists would agree that pathological relationships abound in clinical practice. Consider the carnage of modern
relations: epidemic marital and family discord, crippling separation anxiety, sado-masochistic entanglement, suffocating parent-child
symbiosis, destructive sexual predation, elder abuse and boundary violations. Or even workplace harassment, racism and personal
violence. Most psychiatrists would also agree that something should be done, that all too often, Axis I disorders are refractory,
embedded in disordered personalities and social woes. So the proposal to formalize a relational disorders category has a kind
of intuitive appeal.
But on sober reflection, such a category amounts to an arbitrary enlargement of psychiatry's diagnostic boundaries and to
an uninvited social experiment with unknown consequences. If ratified, untold numbers of individuals will acquire a psychiatric
disorder if they don't already have one. Some have even wondered if this is an APA gambit to loosen the purse strings of managed
care providers.
Crucial questions of definition, reliability, validity and intervention are now being refined just as they were with previous
DSMs. Apparently the research base has crystallized, pointing to the pressing need for psychiatry to push ahead into the social
sphere and curiously recreate the "community psychiatry" of 40 years ago. I'm all for diagnostic precision and comprehensive
treatment, but I shudder at the thought of more DSM diagnostic menus. The rise of the DSMs has unfortunately coincided with
a precipitous fall in clinical understanding. When assessments in other medical specialities have more personal information
than do psychiatric ones, our field has a problem.
So what might these disorders look like? How have these intrepid researchers decided to operationalize "disorders" out of
the tangled welter of social suffering? Strangely enough, they've chosen to focus on that increasingly exotic and fragile
entity: the family. And the relational disorders discussed have that familiar DSM ring: "Marital conflict disorder without
violence," "Marital abuse disorder" (marital conflict disorder with violence), "Parent-child abuse disorder." What is a marital
relationship or a parent-child relationship anyway? Many children experiencing parental divorce and remarriage now have at
least four parents to relate to. Are same-sex marriages included? Common-law marriages? Is spanking a form of domestic violence?
And what of the cultural factors that bear so significantly on family structure, conflict and emotional expression?
"Parent-child abuse disorder" might eventually be part of a larger category of "coercive disorders" yet to be defined, but
future clinicians should brace themselves to enter the minefield of evaluating abusive family relationships. The proposed
framework seems very reasonable, even compelling, until one remembers that it's been created out of thin air.
It also comes at the price of detaching psychiatry even more from the medical model than it already is. By arbitrarily limiting
these disorders to family-based problems, the DSM researchers are choosing to chart some territory and simply not address
the rest. This amounts to a value-laden agenda, rather than one based strictly on advances in medical-scientific knowledge.
The researchers may argue that the social costs of family strife are enormous, but so, for example, are the costs of problematic
workplace relationships, which have been excluded. Within the medical sphere this would be equivalent to declaring that, say,
only certain juveniles with juvenile diabetes had been studied enough to be eligible for the diagnosis. Medicine doesn't work
that way, nor should psychiatry.
Consider some of the criteria discussed for "Marital conflict disorder without violence": repeated deception, sexual dissatisfaction,
failure to control anger, partners feel alone, indifference, deficits in problem-solving communication. The researchers point
to these as indicators of potential relationship deterioration if treatment is not instituted. There is a welcome stipulation
that these experiences be unremitting so as to exclude the temporary blips of married life. However, my experience has been
that such crucial inclusion or exclusion criteria often get used imprecisely in clinical practice.
A kind of diagnostic inflation tends to take place. Disorders such as post-traumatic stress disorder (PTSD) tend to be over-diagnosed
for just this reason. Now individuals complain of a few "flashbacks" after a mild rear-end collision and quickly receive a
diagnosis of PTSD from a primary care practitioner. This is no small event, as a cascade of disability claims and litigation
often ensues. There is also supposed to be, but often isn't, a careful multi-modal assessment prior to the diagnosis of attention-deficit/hyperactivity
disorder. This is especially true in settings under-serviced by psychiatrists. In every area of medicine it is easier to make
a diagnosis than to remove one. Add relational disorders to the mix and many individuals will be accumulating diagnoses like
barnacles.
The researchers call for a careful, integrative evaluation that would address these issues by including direct observation,
interviews, even questionnaires. The time required to do such evaluations properly would be daunting, and such interviews
would be fraught with potential bias, demanding that the practitioner make judgments about highly divergent stories. Are we
ready for this job? And who's going to pay to do it properly?
I would welcome any diagnostic system that restores context to the evaluation of individuals with mental illness. The DSMs
may have refined diagnostic categories but at the cost of a greatly diminished depth of diagnostic understanding. A new category
of relational disorders would add little context and create a few problems of its own.
PETER H. KEEFE is an assistant professor in the Department of Psychiatry, University of Toronto, and a psychotherapy supervisor
at the Centre for Addiction and Mental Health and Mt. Sinai Hospital. He can be reached at ph.keefe@utoronto.ca.
Centre for Addiction
