According to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), relational problems are patterns of interaction between members of a relational unit that are associated with symptoms or significantly impaired functioning in one or more individual members or with significantly impaired functioning of the relational unit itself. DSM-IV-TR distinguishes five categories of relational problems: (1) relational problem related to a mental or general medical condition; (2) parent-child relational problem; (3) partner relational problem; (4) sibling relational problem; and (5) relational problem not otherwise specified.

No reliable figures are available on the prevalence of relational problems. They can be assumed to be ubiquitous; however, most relational problems resolve without professional intervention. The nature, frequency, and effects of the problem on those involved are elements that must be considered before a diagnosis of relational problem is made. For example, divorce, which occurs in just less than 50 percent of marriages, is a problem between partners that is resolved through the legal remedy of divorce and need not be diagnosed as a relational problem. If the persons cannot resolve their disputation and continue to live together in a sadomasochistic or pathologically depressed relationship with unhappiness and abuse, then they should be so labeled. Relationship problems between involved persons that cannot be resolved by friends, family, or clergy require professional intervention by psychiatrists, clinical psychologists, social workers, and other mental health professionals.

According to DSM-IV-TR, the category of relational problem related to a mental disorder or general medical condition “should be used when the focus of clinical attention is a pattern of impaired interaction associated with a psychiatric disorder or a general medical condition in a family member.”

Studies indicate that satisfying relationships may have a health-protective influence, whereas relationship distress tends to be associated with an increased incidence of illness. The influence of relational systems on health has been explained through psychophysiological mechanisms that link the intense emotions generated in human attachment systems to vascular reactivity and immune processes. Thus, stress-related psychological or physical symptoms can be an expression of family dysfunction.

Adults must often assume responsibility for caring for aging parents while they are still caring for their own children, and this dual obligation can create stress. When adults take care of their parents, both parties must adapt to a reversal of their former roles, and the caretakers not only face the potential loss of their parents, but also must cope with evidence of their own mortality.

Some caretakers abuse their aging parents—a problem that is now receiving attention. Abuse is most likely to occur when the caretaking offspring have substance abuse problems, are under economic stress, and have no relief from their caretaking duties, or when the parent is bedridden or has a chronic illness requiring constant nursing attention. More women are abused than men, and most abuse occurs in persons older than the age of 75 years.

The development of a chronic illness in a family member stresses the family system and requires adaptation by both the sick person and the other family members. The person who has become sick must frequently face a loss of autonomy, an increased sense of vulnerability, and sometimes a taxing medical regimen. The other family members must experience the loss of the person as he or she was before the illness, and they usually have substantial caretaking responsibility—for example, in debilitating neurological diseases, including dementia of the Alzheimer’s type, and in diseases such as acquired immunodeficiency syndrome and cancer. In these cases, the whole family must deal with the stress of prospective death as well as the current illness. Some families use the anger engendered by such situations to create support organizations, increase public awareness of the disease, and rally around the sick member. But chronic illness frequently produces depression in family members and can cause them to withdraw from or attack one another. The burden of caring for ill family members falls disproportionately on the women in a family—mothers, daughters, and daughters-in-law.

Chronic emotional illness also requires major adaptations by families. For instance, family members may react with chaos or fear to the psychotic productions of a family member with schizophrenia. The regression, exaggerated emotions, frequent hospitalizations, and economic and social dependence of a person with schizophrenia can stress the family system. Family members may react with hostile feelings (referred to as expressed emotion) that are associated with a poor prognosis for the person who is sick. Similarly, a family member with bipolar I disorder can disrupt a family, particularly during manic episodes.

Family devastation can occur when (1) illness suddenly strikes a previously healthy person, (2) illness occurs earlier than expected in the life cycle (some impairment of physical capacities is expected in old age, although many older persons are healthy), (3) illness affects the economic stability of the family, and (4) little can be done to improve or ease the condition of the sick family member.