I'm O.K. You're O.K. We're Not O.K.

Some psychiatrists want to start treating "DSM-IV", default", relational disorders." Are they nuts?

BY WALTER KIRN

September 16, 2002 Vol. 160 No. 12

There is still only one way to be sane — enjoy your friends, family, faith and job — but every year there are new ways to be crazy. Like the automobile industry, which once sold only sedans and station wagons but now offers endless variations on the SUV (including two versions of the Hummer), the American Psychiatric Association now has an illness for almost every lifestyle. The current edition of its professional bible, the Diagnostic and Statistical Manual of Mental Disorders IV, contains — among scores of other diagnoses — a long list of specialized labels for a condition that was known in my grandmother's era as the jitters, including Attention-Deficit/Hyperactivity Disorder, Social Phobia, Panic Disorder with Agoraphobia, and Panic Disorder Without Agoraphobia.

Given so many maladies to choose from, a person who can't find at least one of his problems covered somewhere in DSM-IV must have something really wrong with him. Unless, that is, his problem is someone else — a child, mate or parent, say. Until recently, being driven mad by others and driving others mad was known as life. It didn't have a name — at least not a medically sanctioned name that could be listed on insurance forms and used in advertisements for pharmaceuticals.

The big news in psychiatry is that this may change. Some powerful practitioners, according to a story that broke in the Washington Post last week, are lobbying for official recognition of a new and controversial category of mental illness: Relational Disorders. Dr. Michael First, associate professor of psychiatry at Columbia University and one of the principal figures behind the push, puts the case for the novel diagnosis this way: "There is evidence that relationships and how people interact in particular relationships can be disordered in a way that's very similar to mental disorders."

That people can make each other nuts — and sometimes seriously, violently nuts — is not a new discovery. My grandmother knew it, and my grandpa too, which is why he kept his power tools in the basement. Still, scientific protocol demands that whenever doctors set out to repackage a perennial human sorrow as a modern, billable disease, they have to act as if they are on to something big. How else could chronic sleepiness have become Primary Hypersomnia?

The process of designating new mental disorders by pretending to misplace everyday experience and then trip over it in the laboratory is easy to satirize, but it has high stakes. If Relational Disorders exist (let's say they do) and doctors or drugs can make them go away (let's say they can, though heaven only knows), then a DSM listing is required or the insurance companies won't pay for treatment. Even with the listing, they are sure to grumble about it. Shelling out for even one-twentieth of the cases of "persistent and painful feelings, behavior and perception involving two or more partners in an important personal relationship" (the proposed definition) could drain the Treasury in about 24 hours.

What makes the proposed diagnosis controversial, aside from the possibility that it could be applied to every living American, is the question of how the "patient" will be defined. A relationship can't make an appointment. Only the individuals in it can. But if only one of them shows up at the clinic, how do you effectively treat the relationship? And if they both come, what if only one feels poorly? For First and his like-minded colleagues, these are sticky issues but solvable ones. They point out that psychiatry deals every day with similar dilemmas and ambiguities. "To me," says First, "the bottom line is treating people. If this is something that can improve people's lives, that's worth the conceptual murkiness."

When a psychiatric disorder makes its debut, patients and doctors join the ticket line first, but eventually the lawyers queue up too. That's when the trouble tends to start. For America's attorneys, who might be said to specialize already in Relational Disorders — in creating them and making them worse — the prospect of such a fuzzy diagnosis must look like a row of cherries on a slot machine. By clouding the notion of personal responsibility even as the classification opens up vast new realms of mutual and collective liability, RD, as it will inevitably be referred to on daytime-TV talk shows, may generate even more in legal fees and damage awards than in insurance reimbursements.

Whatever happens, it won't happen right away. DSM-V will not be published before 2010, giving us plenty of time to ponder the wisdom of formally recognizing a new disease that people can prevent only by living alone in locked rooms that don't have telephones. Maybe the first Relational Disorder that we should be concerned about is the one between psychiatry and the public.

Reported by Sora Song