Washington Post

Doctors Consider Diagnosis for 'Ill' Relationships

By Shankar Vedantam
Washington Post Staff Writer
Sunday, September 1, 2002; Page A01
Washington Post

Some 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.

In 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.

Unlike 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 individuals.

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 group.

Doctors hope that creating a new disease category would encourage systematic study, drug trials and insurance coverage.

The 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 medical ailments.

Psychiatrists 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, as pathological.

The 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.

First 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.

When 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."

"You 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.

"There 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."

The 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.

Relational 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.

"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."

Treating 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.

"If 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."

Family therapists have always worked on relationships to help individuals with psychiatric diagnoses.

"Most 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 your depression."

Beach cited a study that showed that improving couples' relationships was just as effective as treating individuals; both techniques lifted people out of depression.

As 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."

He 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."

Others 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 manual.

"A 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 explained.

Trying 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 University.

"You 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."

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