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Relational Disorders: A New DSM Category?

By Elaine Cassel

The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, categorizes disorders and provides specific criteria for diagnosis. The DSM-IV, published in 1994, is currently being revised. Revisions in presentation of the disorders as well as definitions of new disorders are under consideration. A controversy is brewing over efforts to create a new category—relational disorders.

It has long been the goal of those who study abnormal behavior to classify patterns of such behavior in order to understand and treat the problems. The importance of family and social relationships in triggering dysfunction and providing needed support to treat problems is certainly well documented. Psychodynamic and learning theories of abnormal behavior stress the importance of one’s social environment.

Current therapeutic interventions for some types of emotional and behavioral problems include family members. Family therapy, for instance, involves treatment of two or more individuals from the same family system, one of whom—often a troubled child or adolescent—is the identified client. Family therapy emphasizes the idea that the problems displayed by one family member usually reflect a problem in the entire family’s functioning, and, ultimately, the entire family becomes the client. In addition, couples therapy is aimed at identifying and improving communication between intimate partners.

But should there be a separate category of mental illness that is composed of dysfunctional relationships? Michael First, of Columbia University, an editor of the DSM-IV, thinks so. He proposes that the DSM-V, now in the early stages of revision, create categories of troubled relationships, including those between couples and siblings. He promotes this categorization in order to better understand relationship problems and develop treatments, including medication.

Is it a good idea to label someone with a mental disorder based on problems in their relationships? Where would the line be drawn? What about problems with teachers and supervisors? Could your teachers and bosses try to have you declared mentally ill because you don’t get along? Going a step further, would child abuse and spousal abuse be labeled as relational disorders and treated with drugs or hospitalization? Would there be a search for the genetic or neural underpinnings of dysfunctional relationships?

The opponents of this proposal don’t discount the importance of social and family contexts for people with disorders like depression or anxiety. Former director of the National Institute of Mental Health and now provost of Harvard University Steven Hyman is against the proposal of including a category of relational disorders. He says that a better way to think about things like child and spousal abuse is to understand it as context-dependent, in which other people can and do play a part (Doctors Consider Diagnosis for "Ill" Relationships, The Washington Post, September 1, 2002).

It is not likely that relational disorders will get into the DSM-V, but the debate itself may focus healthy attention on the importance of the social context of mental health and mental illness and actually shift some focus away from medical intervention to the need for social and behavioral interventions when relationships contribute to or cause mental illness.

Elaine Cassel, Marymount University and Lord Fairfax Community College

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