Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment

For a long time now, childhood has not been viewed as a carefree, playful, happy time. Professionals and, increasingly, the public have come to realize that children can suffer from mental disorders and can benefit from treatment. During this time, research has demonstrated the importance of environmental influences on developing personalities and on precipitating mental disorders. These environmental influences are largely mediated by significant relationships, first with parents, then with teachers and peers. Primary relationships are necessary to support the developing child’s curiosity and learning, on the one hand, and to protect the child from danger, on the other.

Moreover, it is now well established that not only infants and children, but also adolescents, adults, and seniors are more likely to thrive in better physical and mental health when they are engaged in mutually satisfying, intimate relationships. Many studies have documented that individuals living in isolation or, perhaps worse, in disordered relationships fare significantly less well. A multitude of “how to” books (e.g., how to be a better parent, how to be a better friend, how to improve your marriage) attest to the widespread dissemination and popular acceptance of these constructs, at least in the modern Western world. Family therapies, couples therapies, and parent-child therapies are the principal ways by which clinicians have addressed these issues.

Yet, as the chapters in this outstanding book demonstrate, the DSM to date has not done justice to the importance of relational processes and relationship disorders. The editors and authors are hopeful that given the explosion in neuroscience and genetic and psychosocial research in these areas, DSM-V will do better.

Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment represents the outcome of two conferences: the Close Relationships Workshop, sponsored by the National Institute of Mental Health (NIMH) in 2001; and a follow-up conference, Relational Processes in Mental Health: From Neuroscience to Assessment and Intervention, sponsored by the Fetzer Institute in collaboration with NIMH. The book is organized into four parts, all dealing with relational processes and relationship disorders: 1) biological underpinnings, 2) assessment, 3) prevention and treatment, and 4) summary and implications for future research. Each part elucidates its topic in a series of chapters written by expert investigators.

Part 1 reviews state-of-the-art biological research that includes imaging studies of brain regions, genetic twin studies, and animal studies that have elucidated brain mechanisms, including synaptic regulation, neurotransmitter dysfunction, immunologic incompetence, and hypothalamic-pituitary-adrenal axis function. All of the studies demonstrate that “disturbances in primary relationships early in life can change neural systems that control emotional resilience and create long-term changes in vulnerability.” More specifically, the brain areas underlying social recognition, social motivation, social approach, and social bonding have been well worked out. Studies in stress neurobiology demonstrate that changes in developing brain neuropeptide systems result from the interaction of specific genes with pre- and postnatal stresses and program an individual “developmental trajectory” that defines subsequent stress vulnerability and resilience and predicts potential psychopathology. The chapters on family-expressed emotion and genetic strategies for delineating relational taxons that end this section are particularly relevant to using relational specifiers as mediators and moderators in DSM-V. Dr. McFarlane reviews data that cogently argue that expressed emotion is not a characteristic of an individual family member, but rather waxes and wanes in the context of the relationship with the patient. Drs. David Reiss and Marianne Wamboldt review genetic and family history literature that argue for the heritable basis of relationship phenotypes that meet criteria of reliability and validity, relate to pathologic mechanisms, and provide a guide to improved treatments and preventative interventions.

Part 2 focuses on assessment of relationships. Dr. George Brown addresses the issues of cut points versus correlations, retrospective versus prospective measurement, and questionnaires versus interviews. He uses his research in childhood maltreatment and adult outcomes as an example. Drs. Beauchaine and Beach provide a sophisticated statistical approach, taxometrics, which offers an advantage over cluster analysis, latent class analysis, and mixture modeling techniques for establishing construct validity. They suggest that taxometrics is well suited for classifying parent-child and marital relationship taxa. In the following chapter, Drs. Heyman and Slep use taxometrics to test whether partner abuse subgroups are truly distinctive. This is a work in progress but certainly illustrates the utility of the method. Other chapters describe the use of the Structural Analysis of Social Behavior model in diagnosing relational disorders and alternative methods of assessing expressed emotion.

Part 3 describes studies that use relational processes in prevention and treatment. For example, in promoting healthy parenting following divorce, Dr. Sandler et al. describe a randomized experimental evaluation of the New Beginnings Program, a relationship based intervention. Dr. Bernal et al. describe outcomes of a psychosocial intervention in depressed Latino adolescents. They suggest that the factor structure of depression (and thus its treatment) differs by ethnic and cultural group that are largely predicated on relational processes. Dr. Mark Whisman concludes Part 3 by providing data and advocating for couples therapy and relationship treatment, especially for individuals with substance abuse disorders, major depression, and panic disorder. The data suggest that treating the relationship results in a better outcome for the individual.

Finally, Part 4 provides an overall summary and recommendations for further research by Dr. David Miklowitz and several of the book’s editors. The authors conclude that current descriptions of relational processes in DSM-IV are “overly vague and general.” They emphasize that the research reviewed in their book mandates, at the least, a systematic description of relational problems as part of a comprehensive assessment of most diagnoses. They suggest that DSM-V should incorporate valid constructs for relational processes and relationship diagnoses (just as with individual constructs). Relational constructs must meet the criteria of 1) a precise clinical description, 2) delineation of syndromes from near-neighbors, 3) delineation of syndromes that have a common outcome, 4) delineation of syndromes that have pathogenic validity, and 5) delineation of syndromes that lead to improved assessments or treatments. Some of the relational constructs already meet these criteria; others require further research. The chapter concludes with several examples of research paradigms, from animal studies to improved assessment—treatment and prevention strategies—that address the validity of relationship constructs.

This book is a relevant summary of the broad range of research focused on relational processes and relationship disorders. Its link to the planning efforts, beginning now for DSM-V, is timely and appropriate; the book nicely underscores the advantages and challenges of having a relational taxonomy in DSM-V. However, the book is more important than just its reference to the next DSM. It is a must read for all mental health professionals and students of human behavior who believe that relationships are an important component of human development, personality, and general well being. The authors of Relational Processes and DSM-V demonstrate their courage. Many investigators would be dissuaded from studying the complexities of relationships as being too difficult. Certainly, funding priorities and previous DSM planning efforts support such advice. Nevertheless, these researchers have persisted. They have used rigorous biopsychosocial paradigms that have conclusively demonstrated the relevance and utility of relational processes for clinicians. If a new relationship axis or additional relationship categories do not appear in DSM-V, given the continued efforts of these investigators, they will certainly do so in DSM-VI.