Sunday, December 13, 2009

Parental Alienation and Mental Illness

by Richard A. Gardner. M.D.
Department of Child Psychiatry, College of Physicians and Surgeons
Columbia University, New York, New York, USA

Child custody evaluators commonly find themselves confronted with resistance when they attempt to use the term parental alienation syndrome (PAS) in courts of law. Although convinced that the patient being evaluated suffers with the disorder, they often find that the attorneys who represent alienated parents, although agreeing with the diagnosis, will discourage use of the term in the evaluators’ reports and testimony. Most often, they will request that the evaluator merely use the term parental alienation (PA). On occasion they will ask whether other DSM-IV diagnoses may be applicable. The purpose of this article is to elucidate the reasons for the reluctance to use the PAS diagnosis and the applicability of PA as well as current DSM-IV substitute diagnoses.


297.3 Shared Psychotic Disorder

  1. A delusion develops in an individual in the context of a close relationship with another person(s) who has an already-established delusion.

  2. The delusion is similar in content to that of the person who already has the established delusion.

This DSM-IV diagnosis is warranted in some of the severe PAS cases in which the programmer is paranoid, and the child’s campaign of denigration incorporates the same paranoid ideation. In a sense, most of the moderate, and even some of the mild cases of PAS, are examples of the folie à deux phenomenon. However, one cannot justifiably consider the mild and moderate cases of PAS to warrant the label psychotic with the implication of complete break with reality. In severe cases we do see bona fide delusions of persecution that can justifiably be considered paranoid. Most often, the delusional system is circumscribed to the alienated parent. It is important to note that this single diagnosis can be applied to both the alienator and the alienated child.

V61.20 Parent-Child Relational Problem

This category should be used when the focus of clinical attention is a pattern of interaction between parent and child (e.g., impaired communication, overprotection, inadequate discipline) that is associated with clinically significant impairment in individual or family functioning or the development of clinically significant symptoms in parent or child.

This diagnosis generally applies to a dyad. Obviously, there are a wide variety of parent-child relational problems that have nothing to do with PAS. In fact, it is reasonable to state that parent-child relational problems probably began with the first families that existed. This diagnosis is an excellent example of the aforementioned principle that none of the DSM-IV diagnoses described here can be reasonably substituted for the PAS. Rather, they are best viewed as disorders that have some symptoms in common with the PAS and may therefore justify being listed as additional diagnoses.

In the PAS situation there is a pathological dyad between the alienating parent and the child and another pathological dyad between the alienated parent and the child. The pathological dyad between the alienated parent and the child is one in which the child is being programmed into a campaign of denigration against the previously loving parent. The child is being programmed to exhibit any and all of the primary symptomatic manifestations of the PAS. With regard to the relationship between the child and the alienated parent, the child exhibits inordinate hostility, denigration, and fear of the target parent to the point where that parent is viewed as noxious and loathsome. Examiners using this criterion do well to emphasize that two separate parent-child relational problems are manifested.

Diagnoses Applicable to Alienating Parents

297.71 Delusional Disorder

  1. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month’s duration.

Of the various subtypes of delusional disorder, the one that is most applicable to the PAS:

Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way

This diagnosis is generally applicable to the PAS indoctrinator who may initially recognize that the complaints about the behavior of the alienated parent are conscious and deliberate fabrications. However, over time, the fabrications may become delusions, actually believed by the programming parent. And the same process may ultimately be applicable to the child. Specifically, at first the child may recognize that the professions of hatred are feigned and serve to ingratiate the child to the programmer. However, over time the child may come to actually believe what were originally conscious and deliberate fabrications. When that point is reached the delusional disorder diagnosis is applicable to the child. Generally, this diagnosis is applicable to relentless programmers who are obsessed with their hatred of the victim parent, by which time the child will have probably entered the severe level of PAS. It is to be noted that when the PAS is present, most often one observes a circumscribed delusional system, confined almost exclusively to the alienated parent. This diagnosis may also be applicable to the PAS child, especially the child who is in the severe category.

301.0 Paranoid Personality Disorder

  1. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
    2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
    3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
    4. reads hidden demeaning or threatening meanings into benign remarks or events
    5. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
    6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
    7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

PAS programmers who warrant this diagnosis would often satisfy these criteria before the marital separation. A detailed history from the victim parent as well as collaterals may be important because the programming parent is not likely to directly reveal such symptoms. They may, however, reveal them in the course of the evaluation, because they are such deep-seated traits, and are so deeply embedded in their personality structure, that they cannot be hidden. Most people involved in protracted child-custody litigation become "a little paranoid," and this is often revealed by elevations on the paranoid scale of the MMPI. After all, there are indeed people who are speaking behind the patient’s back, are plotting against them, and are developing schemes and strategies with opposing lawyers. This reality results in an elevation of the paranoid scale in people who would not have manifested such elevations prior to the onset of the litigation. We see here how adversarial proceedings intensify psychopathology in general (Gardner, 1986), and in this case, paranoid psychopathology especially. The PAS child is less likely to warrant this diagnosis. When the severe level is reached PAS children may warrant the aforementioned Shared Psychotic Disorder diagnosis. On occasion, the diagnosis Schizophrenia, Paranoid Type (295.30) is warranted for the programming parent, but such patients generally exhibited other manifestations of schizophrenia, especially prior to the separation. It goes beyond the purposes of this paper to detail the marital symptoms of schizophrenia which should be investigated if the examiner has reason to believe that this diagnosis may be applicable.

It is important for the examiner to appreciate that there is a continuum from delusional disorder, to paranoid personality disorder, to paranoid schizophrenia. Furthermore, in the course of protracted litigation, a patient may move along the track from the milder to a more severe disorder on this continuum.

301.83 Borderline Personality Disorder (BPD)

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. frantic efforts to avoid real or imagined abandonment.
    Note:Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  3. identity disturbance: markedly and persistently unstable self-image or sense of self
  4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
    Note Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  6. affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
  7. chronic feelings of emptiness
  8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  9. transient, stress-related paranoid ideation or severe dissociative symptoms

Some alienators may exhibit some of these symptoms prior to the separation. However, as a result of the stresses of the separation, the symptoms may progress to the point where the diagnosis is applicable. Criterion (1) is likely to be exhibited soon after the separation because the marital dissolution is generally associated with real feelings of abandonment. Criterion (2) is often seen when there is a dramatic shift from idealization of the spouse to extreme devaluation. The campaign of denigration is the best example of this manifestation of BPD.

Criterion (4) may manifest itself by excessive spending, especially when such spending causes significant stress and grief to the alienated parent. Following the separation, alienating parents may satisfy Criterion (6) with affect instability, irritability, and intense episodic dysphoria. Although such reactions are common among most people involved in a divorce, especially when litigating the divorce, patients with BPD exhibit these symptoms to an even greater degree. Chronic feelings of emptiness (Criterion [7]) go beyond those that are generally felt by people following a separation. Criterion (8) is extremely common among PAS programmers. The tirades of anger against the alienated parent serve as a model for the child and contribute to the development of the campaign of denigration. The stress-related paranoia, an intensification of the usual suspiciousness exhibited by people involved in litigation, may reach the point that Criterion (9) is satisfied.

The examiner should note which of the symptoms are present and comment: "Five criteria need to be satisfied for the BPD diagnosis. Ms. X satisfies four. Although she does not qualify for the diagnosis at this point, she is at high risk for its development. Furthermore, when one lists diagnoses at the end of the report one might note the DSM-IV diagnosis and add in parenthesis "incipient."

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