Relational disorder
Encyclopedia
According to Michael First, MD, of the DSM-5
working committee the locus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship."
Relational disorders involve two or more individuals and a disordered "juncture," whereas typical Axis I psychopathology describes a disorder at the individual
level. An additional criterion for a relational disorder is that the disorder cannot be due solely to a problem in one member of the relationship
, but requires pathological interaction from each of the individuals involved in the relationship.
For example, if a parent is withdrawn from one child but not another, the dysfunction
could be attributed to a relational disorder. In contrast, if a parent is withdrawn from both children, the dysfunction may be more appropriately attributable to a disorder at the individual level.
Dr. First states that "relational disorders share many elements in common with other disorders: there are distinctive features for classification; they can cause clinically significant impairment
; there are recognizable clinical courses and patterns of comorbidity
; they respond to specific treatments
; and they can be prevented with early interventions
. Specific tasks in a proposed research agenda: develop assessment modules; determine the clinical utility of relational disorders; determine the role of relational disorders in the etiology
and maintenance of individual disorders; and consider aspects of relational disorders that might be modulated by individual disorders."
The proposed new diagnosis defines a relational disorder as "persistent and painful patterns of feelings, behaviors, and perceptions" among two or more people in an important personal relationship, such a husband and wife, or a parent and children.
According to psychiatrist Darrel Regier, MD, some psychiatrist
s and other therapists involved in couples and marital counseling have recommended that the new diagnosis
be considered for possible incorporation into the Diagnostic and Statistical Manual of Mental Disorders
(DSM IV).
, MD, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J.L. Moreno, the inventor of psychodrama
and a major pioneer of group psychotherapy
and social psychology
, noted the idea that relationships could be "sick" even if the people involved were otherwise "healthy," and even vice versa: Otherwise "sick" people could find themselves in a mutually supportive and "healthy" relationship.
Moreno's ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what was really going on, the idea of relational disorder was nothing new.
and come to the clinician on their own initiative or are referred by an astute health care professional. Secondly, there is serious violence
in the marriage which is "usually the husband battering the wife." In these cases the emergency room or a legal authority often is the first to notify the clinician.
Most importantly, marital violence "is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed" (National Advisory Council on Violence Against Women
2000). The authors of this study add that "There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology
and control
or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational."
Recommendations for clinicians making a diagnosis of "Marital Relational Disorder" should include the assessment of actual or "potential" male violence as regularly as they assess the potential for suicide
in depressed patients. Further, "clinicians should not relax their vigilance after a battered wife
leaves her husband
, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women.
Many men will stalk
and batter
their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardized interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically."
The authors conclude with what they call "very recent information" on the course of violent marriages which suggests that "over time a husband's battering may abate somewhat, but perhaps because he has successfully intimidated his wife."
The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch. The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.
Some features of abusive parent–child relationships that serve as a starting point for classification include: (a) the parent is physically aggressive with a child, often producing physical injury, (b) parent–child interaction is coercive, and parents are quick to react to provocations with aggressive responses, and children often reciprocate aggression, (c) parents do not respond effectively to positive or prosocial behavior in the child, (d) parents do not engage in discussion about emotions, (e) parent engages in deficient play behavior, ignores the child, rarely initiates play, and does little teaching, (f) children are insecurely attached and, where mothers have a history of physical abuse, show distinctive patterns of disorganized attachment, and (g) parents relationship shows coercive marital interaction patterns.
Defining the relational aspects of these disorders can have important consequences. For example, in the case of early appearing feeding disorders, attention to relational problems may help delineate different types of clinical problems within an otherwise broad category. In the case of conduct disorder
, the relational problems may be so central to the maintenance, if not the etiology, of the disorder that effective treatment may be impossible without recognizing and delineating it.
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
working committee the locus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship."
Relational disorders involve two or more individuals and a disordered "juncture," whereas typical Axis I psychopathology describes a disorder at the individual
Individual
An individual is a person or any specific object or thing in a collection. Individuality is the state or quality of being an individual; a person separate from other persons and possessing his or her own needs, goals, and desires. Being self expressive...
level. An additional criterion for a relational disorder is that the disorder cannot be due solely to a problem in one member of the relationship
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
, but requires pathological interaction from each of the individuals involved in the relationship.
For example, if a parent is withdrawn from one child but not another, the dysfunction
Dysfunction
Dysfunction can refer to:* Abnormality * Dysfunctional family* Sexual dysfunction* Dysfunction , an album by the rock band Staind...
could be attributed to a relational disorder. In contrast, if a parent is withdrawn from both children, the dysfunction may be more appropriately attributable to a disorder at the individual level.
Dr. First states that "relational disorders share many elements in common with other disorders: there are distinctive features for classification; they can cause clinically significant impairment
Impairment
Impairment may refer to:* A medical condition that leads to disability* In accounting, a downward revaluation of fixed assets* In health, any loss or abnormality of physiological, psychological, or anatomical structure or function, whether permanent or temporary...
; there are recognizable clinical courses and patterns of comorbidity
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
; they respond to specific treatments
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
; and they can be prevented with early interventions
Intervention (counseling)
An intervention is an orchestrated attempt by one, or often many, people to get someone to seek professional help with an addiction or some kind of traumatic event or crisis, or other serious problem. The term intervention is most often used when the traumatic event involves addiction to drugs...
. Specific tasks in a proposed research agenda: develop assessment modules; determine the clinical utility of relational disorders; determine the role of relational disorders in the etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
and maintenance of individual disorders; and consider aspects of relational disorders that might be modulated by individual disorders."
The proposed new diagnosis defines a relational disorder as "persistent and painful patterns of feelings, behaviors, and perceptions" among two or more people in an important personal relationship, such a husband and wife, or a parent and children.
According to psychiatrist Darrel Regier, MD, some psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
s and other therapists involved in couples and marital counseling have recommended that the new diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
be considered for possible incorporation into the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM IV).
History
The idea of a psychology of relational disorders is far from new. According to Adam BlatnerAdam Blatner
Adam Blatner, MD, is a Life Fellow of the American Psychiatric Association, doubly Board Certified in Child/Adult Psychiatry), a Certified Trainer of Psychodrama and a psychology theorist. He is the author of the book Acting In, first published in 1973, which became the primary textbook for...
, MD, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J.L. Moreno, the inventor of psychodrama
Psychodrama
Psychodrama is a method of psychotherapy in which clients utilize spontaneous dramatization, role playing and dramatic self-presentation to investigate and gain insight into their lives. Developed by Jacob L. Moreno, M.D. psychodrama includes elements of theater, often conducted on a stage where...
and a major pioneer of group psychotherapy
Group psychotherapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...
and social psychology
Social psychology
Social psychology is the scientific study of how people's thoughts, feelings, and behaviors are influenced by the actual, imagined, or implied presence of others. By this definition, scientific refers to the empirical method of investigation. The terms thoughts, feelings, and behaviors include all...
, noted the idea that relationships could be "sick" even if the people involved were otherwise "healthy," and even vice versa: Otherwise "sick" people could find themselves in a mutually supportive and "healthy" relationship.
Moreno's ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what was really going on, the idea of relational disorder was nothing new.
Kinds of relational disorder
The majority of research on relational disorders concerns three relationship systems: adult children and their parents, minor children and their parents, and the marital relationship. There is also an increasing body of research on problems in dyadic gay relationships and on problematic sibling relationships.Marital relational disorders
Marital disorders are divided into "Marital Conflict Disorder Without Violence" and "Marital Abuse Disorder (Marital Conflict Disorder With Violence)." Couples with marital disorders sometimes come to clinical attention because the couple recognize long-standing dissatisfaction with their marriageMarriage
Marriage is a social union or legal contract between people that creates kinship. It is an institution in which interpersonal relationships, usually intimate and sexual, are acknowledged in a variety of ways, depending on the culture or subculture in which it is found...
and come to the clinician on their own initiative or are referred by an astute health care professional. Secondly, there is serious violence
Violence
Violence is the use of physical force to apply a state to others contrary to their wishes. violence, while often a stand-alone issue, is often the culmination of other kinds of conflict, e.g...
in the marriage which is "usually the husband battering the wife." In these cases the emergency room or a legal authority often is the first to notify the clinician.
Most importantly, marital violence "is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed" (National Advisory Council on Violence Against Women
National Advisory Council on Violence Against Women
In 1995, HHS and DOJ created the National Advisory Council on Violence Against Women, consisting of experts from law enforcement, media, business, sports, health and social services, and victim advocacy...
2000). The authors of this study add that "There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology
Psychopathology
Psychopathology is the study of mental illness, mental distress, and abnormal/maladaptive behavior. The term is most commonly used within psychiatry where pathology refers to disease processes...
and control
Control
Control is the ability to purposefully direct, or suppress, change.Control can also refer to:-Literature:*Tinker, Tailor, Soldier, Spy, "Control" was the head of the Circus, a stand-in for MI-6, in the 1974 British spy novel by John le Carré...
or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational."
Recommendations for clinicians making a diagnosis of "Marital Relational Disorder" should include the assessment of actual or "potential" male violence as regularly as they assess the potential for suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
in depressed patients. Further, "clinicians should not relax their vigilance after a battered wife
Wife
A wife is a female partner in a marriage. The rights and obligations of the wife regarding her spouse and others, and her status in the community and in law, varies between cultures and has varied over time.-Origin and etymology:...
leaves her husband
Husband
A husband is a male participant in a marriage. The rights and obligations of the husband regarding his spouse and others, and his status in the community and in law, vary between cultures and has varied over time...
, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women.
Many men will stalk
Stalk
Stalk may refer to:* Plant stem, one of two main structural axes of a vascular plant* Leaf stalk, also known as Petiole* Flower stalk, also known as Peduncle* Stalking, an act of intrusive behavior or unwanted attention towards a person...
and batter
Batter
Batter may refer to:* Batter * Batter * Batter, * To hit or strike a person, as in committing the crime of battery* To hit or strike a person, as in committing the tort of battery, a common-law offense...
their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardized interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically."
The authors conclude with what they call "very recent information" on the course of violent marriages which suggests that "over time a husband's battering may abate somewhat, but perhaps because he has successfully intimidated his wife."
The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch. The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.
Parent–child abuse disorder
Research on parent–child abuse bears similarities to that on marital violence, with the defining characteristic of the disorder being physical aggression by a parent toward a child. The disorder is frequently concealed by parent and child, but may come to the attention of the clinician in several ways, from emergency room medical staff to reports from child protection services.Some features of abusive parent–child relationships that serve as a starting point for classification include: (a) the parent is physically aggressive with a child, often producing physical injury, (b) parent–child interaction is coercive, and parents are quick to react to provocations with aggressive responses, and children often reciprocate aggression, (c) parents do not respond effectively to positive or prosocial behavior in the child, (d) parents do not engage in discussion about emotions, (e) parent engages in deficient play behavior, ignores the child, rarely initiates play, and does little teaching, (f) children are insecurely attached and, where mothers have a history of physical abuse, show distinctive patterns of disorganized attachment, and (g) parents relationship shows coercive marital interaction patterns.
Defining the relational aspects of these disorders can have important consequences. For example, in the case of early appearing feeding disorders, attention to relational problems may help delineate different types of clinical problems within an otherwise broad category. In the case of conduct disorder
Conduct disorder
Conduct disorder is psychological disorder diagnosed in childhood that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated...
, the relational problems may be so central to the maintenance, if not the etiology, of the disorder that effective treatment may be impossible without recognizing and delineating it.
See also
- DSM-IV CodesDSM-IV CodesDiagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders...
- Relational psychoanalysisRelational psychoanalysisRelational psychoanalysis is a school of psychoanalysis in the United States that emphasizes the role of real and imagined relationships with others in mental disorder and psychotherapy...
- Social psychiatrySocial psychiatrySocial psychiatry is a branch of psychiatry that focuses on the "interpersonal" and cultural context of mental disorder and mental wellbeing. It involves a sometimes disparate set of theories and approaches, with work stretching from epidemiological survey research on the one hand, to an indistinct...
- Social psychology (psychology)
- Social psychology (sociology)Social psychology (sociology)Social psychology , known as sociological social psychology, and sometimes as psychological sociology, is an area of sociology that focuses on social actions and on interrelations of personality, values, and mind with social structure and culture...
- Classification of mental disordersClassification of mental disordersThe classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services...
External links
- Blatner, Adam, MD. Thinking about the diagnosis of Relational Disorders