A recent meta-analysis revealed that mental health and baseline psychological impairment affect the quality of life and outcomes in different chronic conditions. Implementing mental health care in physical care services is still insufficient. Thus, interdisciplinary communication across treatment providers is essential. The standardized language provided by the diagnostic statistical manual favors a clear conceptualization. However, this approach might not focus on the individual, as thinking in categories might impede recognizing the continuum from healthy to diseased. Psychoanalytic theory is concerned with an individual's unconscious conflictual wishes and motivations, manifested through enactments like psychic symptoms or (maladaptive) behavior with long-term consequences if not considered. Such modifiable internal and external factors often are inadequately treated. However, together with the physical chronic condition constraints, these factors determine degrees of freedom for a self-determined existence. The effect of therapeutic interventions, and especially therapy adherence, relies on a solid therapeutic relationship. Outcome and process research still investigates the mechanism of change in psychotherapeutic treatments with psychanalysis's focus on attachment problems. This article examines existing knowledge about the mechanism of change in psychoanalysis under the consideration of current trends emerging from psychotherapy research. A clinical example is discussed. Additionally, further directions for research are given. The theoretical frame in psychoanalytic therapies is the affect-cognitive interface. Subliminal affect-perception is enabled via awareness of subjective meanings in oneself and the other; shaping this awareness is the main intervention point. The interactional ingredients, the patient's inherent bioenvironmental history meeting the clinician, are relevant variables. Several intrinsic, subliminal parameters relevant for changing behavior are observed. Therapeutic interventions aim at supporting the internalization of the superego's functions and at making this ability available in moments of self-reflection. By supporting mentalization abilities, a better understanding of oneself and higher self-regulation (including emotional regulation) can lead to better judgments (application of formal logic and abstract thinking). Thus, this facilitates enduring behavior change with presumably positive effects on mental and physical health.

Nuanced understanding of adolescents' interpersonal relationships with family and peers is important for developing more personalized interventions that prevent problem behaviors and adjustment issues. We used latent profile analysis (LPA) to classify a community sample of 784 adolescents with respect to their observed relationship dynamics with friends and family using videotaped observations and five-minute audiotaped speech samples collected at ages 16-17. The resulting latent classes served to predict behavioral and emotional health in early adulthood. The LPA of the video- and audio-coded observational variables revealed a three-class model: (1) the healthy relationship group (n = 587), representing low levels of deviant and drug use talk with friends and positive, noncoercive relationship with parents; (2) the disaffected group (n = 90), representing high levels of drug use talk with friends and negativity about their parent(s) in the five-minute speech sample; and (3) the antisocial group (n = 107), representing high levels of deviant talk, drug use talk, coercive joining with friends, and coerciveness in family interactions. In contrast to the healthy relationship group, the disaffected group showed elevated risk for substance use problems and depression and the antisocial group showed higher risk for substance use problems and committing violent crimes in early adulthood. Outcome differences between disaffected and antisocial groups were mostly nonsignificant. We discuss the viability of applying these findings to tailoring and personalizing family-based interventions with adolescents to address key dynamics in the family and friendship relationships to prevent adult substance use problems, depression, and violence.

Attempted suicide is a major public health problem.

The aim of this study was to identify patient-identified problems and triggers typically leading to attempted suicide.

A representative sample of 66 adult patients was recruited from all clinical sites and psychiatrists who treat patients after attempted suicide in the Canton of Basel-City (Switzerland). Patients were diagnosed using the Structured Clinical Interview for DSM-IV (SCID) and interviewed with a local adaptation of the Explanatory Model Interview Catalogue (EMIC) to study underlying problems and triggers of attempted suicide.

Of the patients, 92.4% had at least one DSM-IV disorder, with depressive disorders being the most prevalent disorder. Although half (50.0%) of the patients identified a health problem, 71.2% identified an interpersonal conflict as underlying problem leading to the suicide attempt. Furthermore, an interpersonal conflict was identified as the trigger of the suicide attempt by more than half of the patients (54.5%).

The study included German-speaking patients only.

According to patients, interpersonal problems often amplify underlying psychiatric problems, leading to suicide attempts. Social and interpersonal stressors should be acknowledged with integrated clinical and social interventions to prevent suicidal behavior in patients and populations.

Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD).

A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression.

At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up.

For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM-5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths-based orientations, many tensions can follow when use of the DSM-5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM-5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.

To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up.

Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up.

Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity.

Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.

Caregiving relationships are significant factors in the development, mediation, or moderation of childhood mental health problems. However, epidemiological and clinical research has been limited by lack of reliable, succinct, and standardized methods of assessing parent-child relationship constructs. The Relational Processes Workgroup (ad hoc to the DSM-5 process) proposed more specific criteria to define a parent-child relational problem (PCRP). These criteria were field tested in one of the DSM-5 Field trial sites, utilizing a similar research design as DSM-5. Participants included 133 symptomatic children (5-17 years) in active treatment for a mental health problem and their primary caregiver (86% mothers). Two separate clinicians, each blinded to the assessment of the other clinician as well as the DSM-5 diagnoses, interviewed the dyads within a 2-week period, utilizing the proposed PCRP criteria. Prior to each interview, parents were asked to write about their relationship with their child, and children (over the age of 10 years) filled out the Parental Bonding Instrument, Brief Current, and the Perceived Criticism Measure. Clinicians were able to read the narratives and see results of the child report measures before assessing the dyad. The weighted prevalence of a PCRP in this sample was 34%. The interclass kappa for overall agreement between clinicians was 0.58 (0.40, 0.72), which indicates good interrater reliability. Further, clinicians found the PCRP diagnostic criteria clinically useful and an improvement over the brief description of PCRP that was presented in DSM-IV. Relationships between children and their primary caregiver can be assessed in a reliable manner, based on clinical interview with the child-caregiver dyad and several self-report measures.

Emotional and behavioral symptoms and disorders are prevalent in children and adolescents. There has been a burgeoning literature supporting evidence-based treatments for these disorders. Increasingly, family-based interventions have been gaining prominence and demonstrating effectiveness for myriad childhood and adolescent disorders. This article presents the current evidence in support of family-based interventions for mood, anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental particularly autism spectrum, and eating disorders. This review details recent data from randomized controlled trials (RCTs) and promising interventions not yet examined using a randomized controlled methodology. It highlights the evidence base supporting various specific family-based interventions, some of which are disorder dependent. A practitioner perspective is then offered with regard to recommendations for future practice and training. The article closes with a summary and directions for future research.

The reliability and validity of the Diagnostic and Statistical Manual of Mental Disorders-IV Global Assessment of Relational Functioning (GARF) was evaluated in consenting participants presenting to a family therapy training clinic. The purpose of this study was to (a) assess whether the GARF could be administered quickly in a marriage and family therapy training clinic, (b) assess the inter-rater and internal reliability of GARF ratings of intake sessions, (c) examine the relationship of GARF ratings to established measures of relationship functioning, and (d) compare GARF ratings to a measure of depressive symptoms. Study participants completed the General Functioning Subscale of the Family Assessment Device (GFS/FAD), the Quality of Marriage Index (QMI), and the Center for Epidemiologic Studies-Depression Scale (CES-D). After intake sessions were conducted with study participants, GARF ratings were made by an American Association for Marriage and Family Therapy Approved Supervisor or Supervisor-in-Training, a therapist trainee, and two observing trainees who had observed the session from behind a one-way mirror. Cronbach's coefficient alphas and the average intraclass correlation coefficients were both .82 when ratings of the supervisor and two observers were compared and .78 and .79, respectively, when ratings of the supervisor, two observers, and therapist were evaluated. There was significant agreement between GARF ratings made by the supervisor and therapist (but not observers) and scores on the GFS/FAD, QMI, and CES-D. Results suggest that GARF ratings can be made quickly and reliably, especially among raters with greater clinical experience, and are related to measures of relational functioning and depression. Implications for research and marriage and family therapy training are discussed.

This article reviews and critiques the DSM-IV-TR diagnostic criteria for Female Sexual Arousal Disorder (FSAD). An overview of how the diagnostic criteria for FSAD have evolved over previous editions of the DSM is presented and research on prevalence and etiology of FSAD is briefly reviewed. Problems with the essential feature of the DSM-IV-TR diagnosis-"an inability to attain, or to maintain...an adequate lubrication-swelling response of sexual excitement"-are identified. The significant overlap between "arousal" and "desire" disorders is highlighted. Finally, specific recommendations for revision of the criteria for DSM-V are made, including use of a polythetic approach to the diagnosis and the addition of duration and severity criteria.

This article reviews the DSM diagnostic criteria for Female Orgasmic Disorder (FOD). Following an overview of the concept of female orgasm, research on the prevalence and associated features of FOD is briefly reviewed. Specific aspects of the DSM-IV-TR criteria for FOD are critically reviewed and key issues that should be considered for DSM-V are discussed. The DSM-IV-TR text on FOD focused on the physiological changes that may (or may not) accompany orgasm in women; one of the major recommendations here is that greater emphasis be given to the subjective aspects of the experience of orgasm. Additional specific recommendations are made for revision of diagnostic criteria, including the use of minimum severity and duration criteria, and better acknowledgment of the crucial role of relationship factors in FOD.

Relational problems are clinically significant behavioral or psychological syndromes or patterns that occur between or among individuals and that are associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom. Relational problems (e.g., partner relational problems, partner abuse, child maltreatment) are included as Axis I disorders in the DSM-IV as V-codes (i.e., "Other conditions that may be a focus of clinical attention"). However, there are no criteria provided in the DSM-IV for these codes. In this article, we briefly review literature that incontrovertibly documents both relational problems' syndromes/patterns and their serious sequelae. We then review a series of studies that provide evidence of content validity and inter-rater agreement for criteria to determine presence versus absence of relational problems. The most studied subset of relational problem criteria, those for partner and child maltreatment, have been shown to have remarkably high levels of reliability when disseminated broadly in the field (kappa = .66-.89), at agreement levels never reached by DSM diagnoses for individuals. We conclude by arguing that science, service, families, individuals, and the DSM itself, would be well served to include diagnostic criteria for relational problems and to consider the various options for placement of relational problems/processes in the DSM-V.

The study of conflict has dominated psychological research on marriage. This article documents its move from center stage, outlining how a broader canvas accommodates a richer picture of marriage. A brief sampling of new constructs such as forgiveness and sacrifice points to an organizing theme of transformative processes in emerging marital research. The implications of marital transformations are explored including spontaneous remission of distress, nonlinear dynamic systems that may produce unexpected and discontinuous change, possible nonarbitrary definitions of marital discord, and the potential for developing other constructs related to self-transformation in marital research.

The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) has made many strides but can be improved with the addition of relationship descriptions. Relational patterns may result from individual genetic risk factors and thus help to define disorders more clearly. Relationships may also mediate genetic risk factors and be useful in identifying the genetic vulnerability, or they may moderate underlying vulnerable genes so that they are less expressed. Key prototypic relationship patterns have inherent interest to humans, moderate numerous illnesses, and deserve attention in and of themselves. Similar to the use of genetic strategies in clarifying taxons of individual disorders, genetic strategies can help delineate patterns within these key relationships, their common origins, their common outcomes, and their distinctions from near-neighbor patterns.

With the aim of stimulating research in advance of the revision process of the Diagnostic and Statistical Manual of Mental Disorders, "A Research Agenda for DSM-V" (D. A. Kupfer, M. B. First, and D. A. Regier, 2002) was published, highlighting areas for further study. A white paper included in the research agenda (M. B. First et al., 2002) identified the limited provision for the diagnosis of relational disorders as one of the most important gaps in the current DSM-IV (American Psychiatric Association, 1994). Specific recommendations in the research agenda included developing assessment modules, determining the clinical utility of relational disorders, determining the role of relational disorders in the etiology and maintenance of individual mental disorders, and considering aspects of relational disorders that might be modulated by individual mental disorders. In parallel with the 11 research planning conferences organized by the American Psychiatric Association from 2004 to 2007 under the title "The Future of Psychiatric Diagnosis: Refining the Research Agenda," a research planning conference sponsored by the Fetzer Institute was convened to promote research necessary for more empirically informed deliberations about the role of relational disorders in DSM-V. The current special section summarizes the conference proceedings and should serve as a valuable resource for the DSM-V revision process.

The special section addresses a number of salient issues that will arise as the revision process for the Diagnostic and Statistical Manual of Mental Disorders (DSM) unfolds and the role of relational processes in mental health is considered. This collection of articles, which emphasize historical, conceptual, and empirical contributions to the discussion, is intended to stimulate debate in the field and to serve as a resource for individuals charged with proposing new diagnostic guidelines. Jointly, the articles make it clear that the authors can improve on the current treatment of relational processes in the DSM and that there is a solid foundation of family research that can inform any discussion on this topic.

Relational diagnosis has crucial importance in clinical treatment, but its development and inclusion in systems of classification such as the Diagnostic and Statistical Manual has been constrained by a number of factors. First, there is little consensus about what relational assessment and/or diagnosis entails. A second obstacle is the innate complexity of relational assessment and diagnosis, which results in a lack of definitive, well-accepted, evidence-based operational definitions of difficulties. Third, empirical testing of relational issues has lagged well behind the development of elegant theory. A fourth significant block to including relational disorders in the DSM is the discomfort engendered in some quarters about labeling social difficulties as disorders. Finally, the political process that is part of the evolution of diagnostic systems poses difficulties in the acceptance of new disorders or dimensions. This comment on the articles in the special section on relational disorders of the Journal of Family Psychology addresses how each of these articles contributes to overcoming these constraints.