Globe and Mail

Families: A suitable case for treatment?

Monday, September 2, 2002 – Print Edition, Page A1
The Globe and Mail

So you think your family is crazy? You may be closer to the truth than you think.

A group of U.S. psychiatrists wants to create a new category of disorders that would let them diagnose couples who squabble constantly, parents and children who don't get along -- even siblings who clash -- as mentally ill.

Those who might be treated under the proposed "relational disorders" category could be otherwise perfectly healthy and stable: hold steady jobs, have lots of friends and be generally good citizens, pillars of the community and models of balance.

But get them in a room with a certain other person -- say, a sister, son or spouse -- and suddenly all reason flies out the window. The buttons get pushed, the voices start to rise and before they know it, they're at it hammer and tongs.

Voilà: Relational disorder.

In a treatise being circulated by the American Psychiatric Association, the psychiatrists call for the new category to be added to the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM),the bible for mental-health diagnosis published by the association and used around the world, including in Canada.

What makes the proposed new category so radical is that, unlike current psychiatric diagnoses, which identify illnesses solely in individuals, relational disorders would recognize sickness in groups of people and the relationships between them.

But the proposal -- which the doctors say should apply only to family relationships at the moment -- is already raising hackles among psychiatrists. Critics warn it blurs the line between social and medical problems and could be a convenient excuse for everything from road rage to terrorism.

"It certainly would apply to road rage -- there's a model of a relational disorder, par excellence," said Edward Shorter, a professor at the University of Toronto who has written several books on the history of psychiatric medicine.

" 'Our sick highways have made us psychiatrically ill.' "

He worries that the category might be accepted with the understanding that it be applied only in rare, specific circumstances, but then might be expanded to include problems between employees and their bosses, protesters and the government, or a whole host of other social relationships.

"These things can be infinitely applied because they're infinitely subtle.

"Look at what has happened to [posttraumatic stress disorder], for example, which started out with terrible trauma in Vietnam . . . and it ends up that every kid who watches a Batman cartoon gets the diagnosis of PTSD."

The doctors advocating the new classification, led by Michael First, a Columbia University professor and editor of the previous edition of the psychiatric manual, say relational disorders should be included in the DSM because they can cause severe emotional, social and occupational impairment and follow a recognizable clinical course.

The doctors hope the change will lead to earlier identification, better treatment, insurance coverage and more intensive research.

Under the new category, for example, in the case of a mother who bonds with one of her children but withdraws from another, the dysfunction might be attributed to a relational disorder rather than a psychiatric problem that rests solely with the mother.

Both the mother and the child could be diagnosed and treated for mental illness, possibly with drug therapy.

For Prof. Shorter and other critics, the proposal harks back to outdated methods -- the social and community psychiatry of the 1950s and 1960s.

"It really is an attempt to smuggle back into psychiatry ideas that have been discarded: the idea that a sick city makes a sick patient or a sick society makes a sick patient, and people don't really believe that today.

Although social maladies may be a contributing factor in psychiatric illness, today genetics and neurotransmitters have a kind of primacy."

Prof. Shorter says adding the category may only serve to fuel the public's growing skepticism about psychiatry.

"I see the increasing discrediting of the DSM series. Already the awareness is growing that it's just filled with artifacts. If they throw in a major set of artifacts like this, it will increasingly be seen as a political document and not as a scientific document, which is what it set sail as in 1980."

Sally Satel, a U.S. psychiatrist who analyzes mental-health policy and political trends in medicine for the American Enterprise Institute in Washington, points to a considerably more cynical incentive for creating the new category.

"It also opens up more opportunities for billing."

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