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Editorial   |    
Issues for DSM-V: Relational Diagnosis: An Essential Component of Biopsychosocial Assessment
Wayne H. Denton, M.D., Ph.D.
Am J Psychiatry 2007;164:1146-1147. doi:10.1176/appi.ajp.2007.07010181

We are hardwired to seek out attachment, and relational processes will always be an essential part of the human experience (1). Although DSM strives to apply the biopsychosocial model, there is a notable and strikingly absent consideration of the role of relational processes and disorders in the development, maintenance, and manifestations of mental disorders. The development of DSM-V offers an opportunity to correct this deficiency, and such a correction is warranted and vital.

Relational disorders have been defined as “persistent and painful patterns of feelings, behavior, and perceptions involving two or more partners in an important personal relationship” (2, p. 161). The relevance of relational disorders to mental disorders hardly needs to be argued because research is clear that relational processes are important to the development, course, and outcome of mental disorders for both adults and children (e.g., references 3–7). Treatments of mental disorders that target family systems have been shown to have such efficacy (e.g., references 8–10) that the provision of training in couple and family therapy is now a desirable element for psychiatric residency accreditation. Finally, the majority of patients seen by psychiatrists are diagnosed as having problems with their primary support group (11).

A goal of DSM is to facilitate communication, yet it provides no language to discuss relational disorders. It has been noted that “relational disorders are commonly encountered in outpatient mental health practice. Yet the classification scheme offered by DSM-IV…is woefully inadequate in meeting the goals of facilitating communication among clinicians and researchers or in enhancing the clinical management of these conditions” (2, p. 179). In fact, the work group commissioned by APA to evaluate gaps in DSM-IV concluded that one of the two most important such gaps was “the limited provision for the diagnosis of relational disorders” (2, p. 123).

One of the arguments against the inclusion of relational disorders in the DSM system is that they do not fall within the diagnostic definition of “mental disorder” (discussed in reference 12). It is becoming increasingly clear that advances in brain science will eventually render the symptomatic approach to diagnosis embodied in DSM-IV obsolete and that the “intellectual straitjacket” of the current DSM system will have to be loosened (13, p. 1680). Such loosening can open the way to fresh approaches that could include the description of relational disorders.

The ways in which relational diagnosis could be included throughout DSM-V have recently been reviewed by Beach and colleagues (14). For example, relational disorders are already included among the V-codes and could be improved by the development of criteria to increase their reliability and then included in the “official” portion of the nomenclature. Important relational processes, such as expressed emotion, could become part of the text describing associated features in existing conditions (e.g., schizophrenia) (14). These proposals would contribute greatly to the highest priority stated by the framers of DSM, which is for the document to be a helpful guide to clinical practice.

1.Bowlby J: Attachment and Loss, Vol 1: Attachment. New York, Basic Books, 1969
 
2.First MB, Bell CC, Cuthbert B, Krystal JH, Malison R, Offord DR, Reiss D, Shea T, Widiger T, Wisner KL: Personality disorders and relational disorders: a research agenda for addressing crucial gaps in DSM, in A Research Agenda for DSM-V. Edited by Kupfer DJ, First MB, Regier DA. Washington, DC, American Psychiatric Association, 2002, pp 123–195
 
3.Wynne LC, Tienari P, Nieminen P, Sorri A, Lahti I, Moring J, Naarala M, Laksy K, Wahlberg KE, Miettunen J: I: Genotype-environment interaction in the schizophrenia spectrum: genetic liability and global family ratings in the Finnish Adoption Study. Fam Process 2006; 45:419–434
 
4.Wamboldt MZ, Wamboldt FS: Role of the family in the onset and outcome of childhood disorders: selected research findings. J Am Acad Child Adolesc Psychiatry 2000; 39:1212–1219
 
5.Butzlaff RL, Hooley JM: Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry 1998; 55:547–552
 
6.Whisman MA: Marital adjustment and outcome following treatments for depression. J Consult Clin Psychol 2001; 69:125–129
 
7.Whisman MA, Uebelacker LA: Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. J Fam Psychol 2006; 20:369–377
 
8.McFarlane WR, Lukens E, Link B, Dushay R, Deakins SA, Newmark M, Dunne EJ, Horen B, Toran J: Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry 1995; 52:679–687
 
9.Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath RL: A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 2003; 60:904–912
 
10.Diamond G, Josephson A: Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry 2005; 44:872–887
 
11.Pincus HA, Zarin DA, Tanielian TL, Johnson JL, West JC, Pettit AR, Marcus SC, Kessler RC, McIntyre JS: Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network. Arch Gen Psychiatry 1999; 56:441–449
 
12.First MB: Relational processes in the DSM-V revision process: comment on the special section. J Fam Psychol 2006; 20:356–358
 
13.First MB: Beyond clinical utility: broadening the DSM-V research appendix to include alternative diagnostic constructs. Am J Psychiatry 2006; 163:1679–1681
 
14.Beach SRH, Wamboldt MZ, Kaslow NJ, Heyman RE, Reiss D: Describing relationship problems in DSM-V: toward better guidance for research and clinical practice. J Fam Psychol 2006; 20:359–368
 

+Address correspondence and reprint requests to Dr. Denton, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9121; wayne.denton@utsouthwestern.edu (e-mail). Editorial accepted for publication March 2007 (doi: 10.1176/appi.ajp.2007.07010181).

+Dr. Denton reports no competing interests.

+Editorials discussing other DSM-V issues can be submitted to the Journal at http://mc.manuscriptcentral.com/appi-ajp. Submissions should not exceed 500 words.

+

References

1.Bowlby J: Attachment and Loss, Vol 1: Attachment. New York, Basic Books, 1969
 
2.First MB, Bell CC, Cuthbert B, Krystal JH, Malison R, Offord DR, Reiss D, Shea T, Widiger T, Wisner KL: Personality disorders and relational disorders: a research agenda for addressing crucial gaps in DSM, in A Research Agenda for DSM-V. Edited by Kupfer DJ, First MB, Regier DA. Washington, DC, American Psychiatric Association, 2002, pp 123–195
 
3.Wynne LC, Tienari P, Nieminen P, Sorri A, Lahti I, Moring J, Naarala M, Laksy K, Wahlberg KE, Miettunen J: I: Genotype-environment interaction in the schizophrenia spectrum: genetic liability and global family ratings in the Finnish Adoption Study. Fam Process 2006; 45:419–434
 
4.Wamboldt MZ, Wamboldt FS: Role of the family in the onset and outcome of childhood disorders: selected research findings. J Am Acad Child Adolesc Psychiatry 2000; 39:1212–1219
 
5.Butzlaff RL, Hooley JM: Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry 1998; 55:547–552
 
6.Whisman MA: Marital adjustment and outcome following treatments for depression. J Consult Clin Psychol 2001; 69:125–129
 
7.Whisman MA, Uebelacker LA: Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. J Fam Psychol 2006; 20:369–377
 
8.McFarlane WR, Lukens E, Link B, Dushay R, Deakins SA, Newmark M, Dunne EJ, Horen B, Toran J: Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry 1995; 52:679–687
 
9.Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath RL: A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 2003; 60:904–912
 
10.Diamond G, Josephson A: Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry 2005; 44:872–887
 
11.Pincus HA, Zarin DA, Tanielian TL, Johnson JL, West JC, Pettit AR, Marcus SC, Kessler RC, McIntyre JS: Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network. Arch Gen Psychiatry 1999; 56:441–449
 
12.First MB: Relational processes in the DSM-V revision process: comment on the special section. J Fam Psychol 2006; 20:356–358
 
13.First MB: Beyond clinical utility: broadening the DSM-V research appendix to include alternative diagnostic constructs. Am J Psychiatry 2006; 163:1679–1681
 
14.Beach SRH, Wamboldt MZ, Kaslow NJ, Heyman RE, Reiss D: Describing relationship problems in DSM-V: toward better guidance for research and clinical practice. J Fam Psychol 2006; 20:359–368
 
+
+

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