Parental Alienation is in the DSM-5-TR,
But Not the Actual Words: APA Experts Agree
William Bernet, M.D., and Amy J. L. Baker, Ph.D.
We have said for years that the concept of parental alienation is in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), even if the actual words have not been included. New information is that senior officials at the American Psychiatric Association (APA) have unequivocally confirmed that parental alienation is included in parent–child relational problem (PCRP), one of the mental conditions in the DSM-5-TR.
Parental Alienation and Parent–Child Relational Problem
With the help of several members of Parental Alienation Study Group, we submitted three proposals regarding parental alienation to the Steering Committee, the component of the APA that considers possible additions and corrections to the DSM-5-TR. Although our proposals were rejected, the leadership of the Steering Committee repeatedly explained it is not necessary to add “parental alienation” or simply “alienation” to the DSM-5-TR because the concept is already included in the definition of PCRP.
We received multiple messages from Lamyaa Yousif, M.D., Ph.D., M.Sc., Senior DSM Operations Manager, who said:
It is not necessary to add the term “parental alienation” as an example of parent/child relational problems, since the description of parent/child relational problems already encompasses the kind of interactions often designated as “parental alienation.” (Email from Lamyaa Yousif to William Bernet, July 27, 2023)
Subsequently, Dr. Yousif repeated that it is unnecessary to add the word “alienation” to the description of PCRP:
[T]he current description [of PCRP] is inclusive of situations in which a child’s relationship with one parent may be adversely affected by pressure from the other parent.” (Email from Lamyaa Yousif to William Bernet, September 12, 2023)
The chairperson of the Steering Committee, Paul S. Appelbaum, Ph.D., endorsed the messages from Dr. Yousif and added that we are welcome to share these opinions of the Steering Committee with mental health and legal professionals and the general public. The conclusion of the Steering Committee—that the definition of PCRP includes the concept of parental alienation—were also endorsed by William E. Narrow, M.D., and Marianne Z. Wamboldt, M.D. Dr. Narrow and Dr. Wamboldt were the authors of the description of PCRP in DSM-5-TR.
There is a lack of transparency in the methods that the Steering Committee employs when considering additions and corrections to DSM-5-TR. The deliberations of the Committee are considered confidential. We proposed to meet face-to-face with the members of the Steering Committee in order to understand their opinions regarding parental alienation, but they declined to engage in that type of dialogue. We invited Dr. Appelbaum, the chairperson of the Steering Committee, to review this short article prior to its publication. He simply replied: “As I indicated previously, you are free to share our communications with you, including those cited in this piece” (Email from Paul S. Appelbaum to William Bernet, September 18, 2023).
Comparing DSM-5-TR and ICD-11
This determination by the DSM-5-TR Steering Committee—that parental alienation is already included in the description of PCRP—has important implications for mental health practitioners. That is, when psychiatrists and psychologists recognize a child or family member as experiencing parental alienation, it is appropriate to identify them with the term, parent–child relational problem (Z62.820).
A similar policy is in place with regard to the International Classification of Diseases,11th Edition (ICD-11), the book of diagnoses published by the World Health Organization. Personnel at ICD-11 have provided explicit guidance to the effect that children diagnosed with parental alienation may be identified as having the ICD-11 condition, caregiver–child relationship problem. The website of the World Health Organization states: “In situations in which an individual labeled with [parental alienation] presents for health care, other ICD-11 content is sufficient to guide coding. Users may classify cases to ‘caregiver–child relationship problem’” (https://www.who.int/standards/classifications/frequently-asked-questions/parental-alienation).
Thus, parental alienation is not a free-standing diagnosis in either DSM-5-TR or ICD-11. However, these two diagnostic systems are consistent in that both of them allow for the coding of cases involving parental alienation. In the DSM-5-TR, parental alienation may be identified as parent–child relational problem (Z62.820); in the ICD-11, parental alienation may be identified as caregiver–child relationship problem (QE52.0).
Alternative Diagnoses for Cases of Parental Alienation
The recent communications from the DSM-5-TR Steering Committee focused on the mental condition PCRP. Several DSM-5-TR diagnoses may be appropriate to use in cases of parental alienation, depending on the details of the clinical presentation and the focus of clinical attention. For example:
Parent–child relational problem (PCRP) (Z62.820). The definition of this mental condition includes: “. . . negative attributions of the other’s intentions, hostility toward the other, and unwarranted feelings of estrangement.” The diagnosis of PCRP would be appropriate if the focus of clinical attention is on the relationship between the alienated child and the alienated parent.
Child affected by parental relationship distress (CAPRD) (Z62.898). The definition of CAPRD includes “. . . negative effects of parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a child in the family.” The diagnosis of CAPRD would be appropriate if the focus of clinical attention is on the mental condition of the alienated child (Bernet, Wamboldt, & Narrow, 2016).
Child psychological abuse (T74.32XA). The definition for this mental condition includes: “. . . harming/abandoning people or things that the child cares about.” The diagnosis of child psychological abuse can be given to the adult perpetrator of maltreatment or the child victim of maltreatment. This diagnosis would be appropriate if the focus of clinical attention is on the activities of an abusive, alienating parent (Kruk, 2018).
Delusional symptoms in the context of relationship with an individual with prominent delusions (F28). This is DSM-5-TR terminology for the mental disorder that previously was called folie à deux and shared psychotic disorder.In severe cases of parental alienation, the underlying explanation might be a delusional disorder in the favored parent. In such a case, it would be appropriate to diagnose the child with delusional symptoms in the context of relationship with an individual with prominent delusions (Tucker & Cornwell, 1977).
Factitious disorder imposed on another (F68.A). This is DSM-5-TR terminology for the mental disorder that previously was called factitious disorder by proxy. In some cases of parental alienation, the alienating parent might falsify physical or psychological signs or symptoms in order cause the child to appear ill, injured, or abused. In such a case, it would be appropriate to diagnose the perpetrator (not the child) with factitious disorder imposed on another (Bütz, 2020).
Identity disturbance due to prolonged and intense coercive persuasion (F44.89). In some cases of parental alienation, the child who has been subjected to intense coercive persuasion (e.g., indoctrination, thought reform) may present with prolonged changes in, or conscious questioning of, their identity. In such a case, it would be appropriate to diagnose the child with identity disturbance due to prolonged and intense coercive persuasion.
Conclusions
Although the actual words “parental alienation” are not found in the DSM-5-TR, there are many ways for clinicians to identify a child or family member who are experiencing the pathological triadic relationship that characterizes this mental condition. It may be appropriate to use multiple diagnoses for the family members depending on the focus of clinical attention. For example, a parent manifesting a severe level of alienating behaviors might be identified as being a perpetrator of child psychological abuse, while the maltreated child might be identified as having CAPRD. The complete definitions and descriptions of these conditions are found in the current edition of DSM-5-TR. Practitioners evaluating a child or a family that might be experiencing parental alienation are advised to: collect clinical information from multiple sources; consider all the possible underlying causes of contact refusal or parent–child contact problems; and carefully apply the criteria for the pertinent mental disorders and conditions.
References
Bernet W, Wamboldt MZ, & Narrow WE (2016). Child affected by parental relationship distress. Journal of the American Academy of Child and Adolescent Psychiatry, 55(7), 571– 579.
Bütz MR (2020). Parental Alienation and Factitious Disorder by Proxy Beyond DSM-5: Interrelated Multidimensional Diagnoses. New York, NY: Routledge.
Kruk E (2018). Parental alienation as a form of emotional child abuse: Current state of knowledge and future directions for research. Family Science Review, 22(4), 141–164.
Tucker LS & Cornwall TP (1977). Mother-son folie à deux: A case of attempted patricide. American Journal of Psychiatry, 134(10), 1146–1147.