Other Conditions
Malingering
Malingering is the deliberate falsification of physical or psychological symptoms to achieve a secondary gain (e.g., avoiding duty, financial compensation).
It may be adaptive in certain circumstances (e.g., feigning illness as a war captive).
Consider malingering when:
There is a medicolegal context.
There is a discrepancy between claimed stress/disability and objective findings.
There is a lack of cooperation during evaluation and treatment.
Antisocial personality disorder is present.
Diagnosis and Clinical Features
Avoidance of Criminal Responsibility: Criminals may feign incompetence to avoid trial or punishment.
Avoidance of Military Service: Individuals may malinger to avoid conscription or hazardous duties.
Financial Gain: Malingerers may seek undeserved benefits (e.g., disability insurance, workers' compensation).
Avoidance of Work/Social Responsibility: Individuals may malinger to escape unpleasant situations or consequences.
Facilitation of Transfer from Prison to Hospital: Prisoners may fake symptoms to transfer to a psychiatric hospital.
Prison context may also lead to dissimulation (faking good) to avoid extended stays on mental health wards.
Admission to a Hospital: Individuals may malinger to gain free room and board in a psychiatric hospital.
Drug Seeking: Individuals may feign illness to obtain favored medications for personal use or trade within prison.
Child Custody: Parties may minimize difficulties or fake good to obtain child custody.
Differential Diagnosis
Differentiate malingering from actual physical or psychiatric illness.
Consider partial malingering (exaggeration of existing symptoms).
Consider unintentional misattribution of genuine symptoms to an incorrect cause.
Real psychiatric disorder and malingering are not mutually exclusive.
Distinguish from factitious disorder by motivation (sick role vs. tangible gain).
Somatoform disorders involve no conscious volition.
Differentiation between conversion disorder and malingering can be difficult.
Table 20-2 lists variables aiding differentiation between malingering and conversion disorder.
Epidemiology
Prevalence of malingering: ~1% among mental health patients, ~5% in the military.
Higher prevalence in litigious contexts (10-20% of criminal defendants).
Lying-related issues reported in ~50% of children with conduct disorders.
No clear familial or genetic patterns, sex, or age bias.
Highly prevalent in military, prison, and litigious populations, especially young to middle-aged men in Western societies.
Associated disorders: conduct and anxiety disorders in children; antisocial, borderline, and narcissistic personality disorders in adults.
Etiology
No known biological factors directly cause malingering.
Frequent association with antisocial personality disorder raises the possibility of hypoarousability as an underlying factor.
No known predisposing genetic, neurophysiologic, neurochemical, or neuroendocrinologic forces.
Course and Prognosis
Malingering persists as long as it yields desired rewards.
Symptoms disappear after the goal is achieved (in the absence of concurrent diagnoses).
In structured settings, ignoring malingered behavior may lead to its disappearance.
In children, malingering is often associated with anxiety or conduct disorder.
Treatment
The appropriate stance for the psychiatrist is clinical neutrality.
Conduct a careful differential investigation if malingering is suspected.
Confront the patient tactfully but firmly if malingering seems most likely.
Explore the underlying reasons for the ruse and suggest alternative pathways.
Assess coexisting psychiatric disorders thoroughly.
Abandon interaction only if the patient is utterly unwilling to interact under any terms other than manipulation.
Bereavement
Normal bereavement begins soon after the loss of a loved one.
Symptoms include sadness, preoccupation, tearfulness, irritability, insomnia, and difficulty concentrating.
Duration varies by culture, usually up to 6 months, but may be longer.
Normal bereavement can lead to a major depressive disorder requiring treatment.
Depressive disorder is generally not diagnosed unless symptoms persist 2 months after the loss.
Specific symptoms differentiating bereavement from depression include:
Guilt about things other than actions taken or not taken at the time of death.
Thoughts of death other than feeling better off dead or dying with the deceased.
Morbid preoccupation with worthlessness.
Marked psychomotor retardation.
Prolonged and marked functional impairment.
Hallucinatory experiences other than transiently seeing/hearing the deceased.
Occupational Problems
Occupational problems often arise during stressful work changes (entry, job changes, layoffs, retirement).
Work distress can result from work overload or lack of challenge.
Inability to fulfill work expectations or conflicting expectations can cause distress.
Harsh or unreasonable superiors are a common source of work distress.
Work Choices and Changes
Young adults often underestimate their potential abilities.
Women and minorities may feel less prepared for challenges and fear rejection.
Men in underrepresented fields may advance faster (glass elevator).
Patients should consider unrecognized talents, unexpressed dreams, successes, and motivation.
Minorities and those in low-paying jobs have less job security.
Downsizing, factory closings, and moves affect many workers, leading to feelings of hopelessness and anger.
Men define themselves by work roles; women may adjust faster to retirement but have less financial security.
White women earn approximately 80 cents on the dollar, and minorities earn even less.
Women may have lower status, be widowed more often, and care for dependents.
Stress and the Workplace
Over 30% of workers report stress at work.
At least 15% of occupational disability claims involve workplace distress.
Expected distress follows work changes (downsizing, mergers, overload) and strains (noise, temperature, injuries).
Work frustration can arise from unresolved psychodynamic issues.
Developmental issues include problems with competition, assertiveness, envy, and communication.
Work conflicts often reflect personal life conflicts; treatment referral is in order.
Massage therapy, meditation, and yoga can relieve stress.
Cognitive therapy approaches can reduce work pressure.
Suicide Risk
Certain occupations (health professionals, financial service workers, police) have higher suicide risk.
This is due to access to lethal means and increased chronic distress.
Career and Job Problems of Women
Most women work out of necessity or as part of a working couple.
Divorce can economically impoverish women.
Unique gender issues, bias, and lack of accommodation for life stages (pregnancy, childcare) continue.
Women were the largest group establishing new small businesses in the 1990s.
Problems occur when they are the sole woman in a man’s field.
Fewer than 25% of men equitably share home and family responsibilities.
Women of childbearing and child-rearing ages face conflict with job expectations and responsibilities.
High-quality, on-site, dependent-care facilities with extended hours are rare.
Unresolved work issues include flextime and paid/unpaid dependent leave options.
Distress continues after chronic sexual harassment, despite its illegality.
More women have travel responsibilities, work long hours, and experience workplace violence.
In dual-career families, women are more likely to move for their partner's job.
There is less hesitation for couples to work for the same organization.
Work distress may stem from gender-based miscommunication.
Working Teenagers
With unemployment increasing, many teenagers work part time.
Stress can arise due to less parent-teen interaction and control issues.
When all parents and teens work, proactive communication is essential.
Working within the Home
Problems may develop from perceived expectations between partners.
Women caring for children and home may be seen as economically dependent and incompetent.
Ongoing respectful communication is crucial.
Taking work home can interfere with personal lives and satisfaction.
Chronic Illness
Employers are increasingly concerned about accommodating patients with chronic diseases.
Mandatory testing for AIDS and substance abuse is a concern.
Employee assistance programs offering general and mental health education are cost-effective.
Domestic Violence
Signs and symptoms interfering with work may identify victims of domestic violence.
Trained professionals must question employees experiencing work distress.
Referrals for assistance, including workplace safety, are essential.
Job Loss
Job loss causes distress, including grief, loss of self-esteem, anger, and reactive symptoms.
Substance abuse or domestic violence may increase.
Education, support programs, and vocational guidance can be helpful.
Vocational Rehabilitation
Rehabilitation is necessary for those traumatized or who lose their jobs.
Counseling enables people to improve relationships, raise self-esteem, or learn skills.
Patients with schizophrenia may benefit from sheltered workshops.
Some excel in repetitive or detail-oriented tasks.
Adult Antisocial Behavior
Antisocial behavior is characterized by illegal or immoral activities that begin in childhood.
The term applies to actions not due to a mental disorder and to actions by those who have not received a neuropsychiatric workup.
It can apply to behavior by normal persons making a "dishonest living."
Diagnosis and Clinical Features
Diagnosis is one of exclusion.
Substance dependence often makes it difficult to separate antisocial behavior related primarily to substance dependence from disordered behavior.
This must be differentiated from antisocial personality disorder.
The diagnosis of antisocial personality disorder supersedes a diagnosis of antisocial behavior.
Manic phases of bipolar I disorder can mimic antisocial behavior.
Patients with schizophrenia may have episodes of adult antisocial behavior.
A full workup, including neuroimaging, can help identify neurologic causes.
Consider complex partial seizures in the differential diagnosis.
Abnormal EEG findings are prevalent among violent offenders.
Adult antisocial behavior manifests as difficulties in work, marriage, finances, and conflicts with authorities.
Table 20-3 summarizes the symptoms of adult antisocial behavior.
Epidemiology
Adult antisocial behavior may range from 5 to 15% of the population.
Within prison populations, prevalence figures are between 20 and 80%.
Men account for more adult antisocial behavior than women.
Etiology
Antisocial behaviors in adulthood are characteristic of those with no demonstrable psychopathology to those who are severely impaired.
A comprehensive neuropsychiatric assessment of antisocial adults is indicated.
Only in the absence of mental disorders can patients be categorized as displaying adult antisocial behavior.
Genetic Factors
Some studies found a 60% concordance rate in monozygotic twins and about a 30% concordance rate in dizygotic twins.
Adoption studies show a high rate of antisocial behavior in the biologic relatives of adoptees identified with antisocial behavior and a high incidence of antisocial behavior in the adopted-away offspring of those with antisocial behavior.
Prenatal and perinatal periods of those who subsequently display antisocial behavior are often associated with low birth weight, mental retardation, and prenatal exposure to alcohol and other drugs of abuse.
Social Factors
Offenses more likely to be committed in low socioeconomic neighborhoods.
Middle-SES parents withdraw affection; low-SES parents use physical punishment.
Adult antisocial behavior is associated with the use and abuse of alcohol and other substances and with the easy availability of handguns.
Treatment
Therapists are pessimistic about treating adult antisocial behavior.
Psychotherapy has not been effective.
Therapists show more enthusiasm for other forms of group treatment.
Many adult criminals have shown some response to group therapy approaches.
Violent, criminal behaviors seem to decrease after age 40.
Recidivism in criminals also decreases in middle age.
Prevention
Primary focus should be on delinquency prevention as antisocial behavior often begins during childhood.
Measures to improve the physical and mental health of disadvantaged children: educate parents about CNS injury dangers and the effects of alcohol on the brain.
Opponents of capital punishment see it as “vengeance,” not punishment.
The media can transmit positive social values.
Successful preventive measures come from public health programs and monitoring vulnerabilities.
Religious or Spiritual Problem
Religious or spiritual problems can bring a person to a psychiatrist.
A person may question faith or wish to convert.
Psychiatrists must assist patients in distinguishing religious thought or experience from psychopathology.
Religious imagery may be recognized in mental illness when persons state that they have been commanded by God to take a dangerous or grandiose action.
Cults
Cults are led by charismatic leaders with unethical values.
Cult members are actively controlled and forced to dissolve allegiance to family.
Deprogramming and adjustment are time-intensive, long-term, and can result in posttraumatic stress disorder (PTSD).
Acculturation Problem
Acculturation is adapting to a different culture, leading to assimilation.
Culture shock can evoke severe distress.
Children and young adult immigrants adapt more quickly.
Culture shock can occur within a person’s own country.
Reactive symptoms include anxiety, depression, isolation, and fear.
Constant geographic moves involve a large proportion of workers in the United States.
Joining activities in the new community and actively trying to meet neighbors and coworkers can lessen the culture shock.
Brainwashing
Brainwashing is the deliberate creation of culture shock.
Individuals are isolated, intimidated, and made to feel different to break their spirits and destroy their coping skills.
Brainwashed individuals with PTSD require deprogramming treatment.
Treatment is usually long-term to rebuild healthy self-esteem and coping skills.
Prisoners of War and Torture Victims
Survivors have personal inner strengths developed in earlier lives or are more likely to commit suicide otherwise.
Prisoners cope with anxiety, fear, isolation, and loss of control.
Those who appear to cope best believe they must survive for a reason and maintain mental connections to their past values and experiences.
The family may be affected by the survivor's fears, overprotection, lack of sharing, or anger.
Another generation can be affected in their personal development and psychological functioning and may require psychiatric evaluation and treatment.
Phase of Life Problem
Phase of life problems may occur at any point along the life cycle.
Multiple, significant negative occurrences overwhelm a person’s ability to recover and function constructively.
Significant life changes precipitate distress in the form of anxiety and depressive symptoms.
Individuals with positive attitudes, healthy relationships, and mature defense mechanisms appear to be best able to cope.
Noncompliance with Treatment
Noncompliance with treatment involves how well a patient follows the recommendations provided by the physician.
A positive doctor-patient relationship can help foster compliance but that does not guarantee it.
In psychiatry, one major concern is with medication adherence, given unpleasant side effects, personal preferences, and/or denial of illness.
Only use this category of "Other conditions that may be a focus of clinical attention" when the problem is severe enough to warrant independent clinical attention.
Relational Problems
An adult’s psychological health and sense of well-being depend, to a significant degree, on the quality of his or her critical relationships.
Problems in the interaction between any of these significant others can lead to clinical symptoms and impaired functioning among one or more members of the relational unit.
Relational problems may be a focus of clinical attention when:
A relational unit is distressed and dysfunctional or threatened with dissolution and
The relational problems precede, accompany, or follow other psychiatric or medical disorders.
Indeed, the relational context of the patient influences other medical or psychiatric symptoms.
Conversely, the functioning of a relational unit is affected by a member’s general and other medical or psychiatric illness.
Relational disorders require a different clinical approach than other disorders.
Instead of focusing primarily on the link between symptoms, signs, and the workings of the individual mind, the clinician must also focus on interactions between the individuals involved.
Also, the clinician should consider how these interactions are related to the general and other medical or psychiatric symptoms in a meaningful way.
Definition
Relational problems are patterns of interaction between members of a relational unit that are associated with significantly impaired functioning in one or more individual members.
Thus one may have parent–child problems, sibling-related problems, or other dyad or triad impairments.
At times the entire unit, such as the family itself, may be dysfunctional.
Epidemiology
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.
We should consider the nature, frequency, and effects of the problem on those involved before using this diagnosis.
For example, divorce, which occurs in just under 50 percent of marriages, is a problem that partners resolve through the remedy of divorce.
We do not need to use this diagnosis for most divorces.
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.
Relational Problem Related to a Mental Disorder or General Medical Condition
When a family member is ill either from a psychiatric or medical illness, there are reverberations throughout the family unit.
Studies indicate that whereas satisfying relationships may have a health-protective influence, relationship distress tends to be associated with an increased incidence of illness.
Psychophysiologic mechanisms help to explain how relational systems affect physical or mental health.
For example, the intense emotions generated in human attachment systems can affect 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 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 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.
Women suffer abuse more often than men, and most abuse occurs in persons older than age 75 years.
The development of 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 neurologic diseases, including dementia of the Alzheimer’s type, and diseases such as AIDS 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.
However, 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 of 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 illness suddenly strikes a previously healthy person, occurs earlier than expected in the life cycle (some impairment of physical capacities is expected in old age, although many older persons are healthy), affects the economic stability of the family, and when there are few options for improving the condition of the sick family member.
Parent–Child Relational Problem
Parents differ widely in sensing the needs of their infants. Some quickly note their child’s moods and needs; others are slow to respond.
Parental responsiveness interacts with the children’s temperament to affect the quality of the attachment between child and parent.
The diagnosis of the parent–child relational problem applies when the focus of clinical attention is a pattern of interaction between parent and child that is associated with clinically significant impairment in individual or family functioning or with clinically significant symptoms.
Examples include impaired communication, overprotection, and inadequate discipline.
Research on parenting skills has isolated two primary dimensions: (1) a permissive–restrictive dimension and (2) a warm and accepting versus a cold and hostile dimension.
A typology that separates parents on these dimensions distinguishes among authoritarian (restrictive and cold), permissive (minimally restrictive and accepting), and authoritative (restrictive as needed but also warm and accepting) parenting styles.
Children of authoritarian parents tend to be withdrawn or conflicted; those of permissive parents are likely to be more aggressive, impulsive, and low achievers; and children of authoritative parents seem to function at the highest level, socially and cognitively.
However, switching from an authoritarian to a permissive mode may create a negative reinforcement pattern.
Difficulties in many situations stress the usual parent–child interaction.
Substantial evidence indicates that marital discord leads to problems in children, from depression and withdrawal to conduct disorder and poor performance at school.
Parents may resort to triangulation, where they recruit a child as an ally in the struggle with the partner.
Divorces and remarriages stress the parent–child relationship and may create painful loyalty conflicts.
Stepparents often find it challenging to assume a parental role and may resent the special relationship that exists between their new marital partner and the children from that partner’s previous marriages.
The resentment of a stepparent by a stepchild and the favoring of a natural child are usual reactions in a new family’s initial phases of adjustment.
When a second child is born, both familial stress and happiness may result, although happiness is the dominant emotion in most families.
The birth of a child can also be troublesome when parents had adopted a child in the belief that they were infertile.
Single-parent families usually consist of a mother and children, and their relationship is often affected by financial and emotional problems.
Other situations that can produce a parent–child problem are the development of fatal, disabling, or chronic illness, such as leukemia, epilepsy, sickle-cell anemia, or spinal cord injury, in either the parent or child.
The birth of a child with congenital disabilities, such as cerebral palsy, blindness, or deafness, may also produce parent–child problems.
These situations challenge the emotional resources of those involved.
Parents and the child must face present and potential loss and must adjust their day-to-day lives physically, economically, and emotionally.
These situations can strain the healthiest families and produce parent–child problems not only with the sick person but also with the unaffected family members.
In a family with a severely sick child, parents may resent, prefer, or neglect the other children because the ill child requires much time and attention.
Parents with children who have emotional disorders face particular problems, depending on the child’s illness.
In families with a child with schizophrenia, family treatment is beneficial and improves the social adjustment of the patient.
Similarly, family therapy is useful when a child has a mood disorder.
In families with a substance-abusing child or adolescent, family involvement is crucial to help control the drug-seeking behavior and to allow family members to verbalize the feelings of frustration and anger that are invariably present.
Normal developmental crises can also be related to parent–child problems.
For instance, adolescence is a time of frequent conflict as the adolescent resists rules and demands, increasing autonomy and, at the same time, elicits protective control by displaying immature and dangerous behavior.
Daycare Centers
Quality of care during the first 3 years of life is crucial to neuropsychologic development.
The National Institute of Child Health and Human Development does not consider daycare harmful to children especially when the caregivers and daycare teachers provide consistent, empathetic, nurturing care.
Not all daycare centers can meet that level of care, however, especially those located in impoverished urban areas.
Children receiving less than optimal caring exhibit decreased intellectual and verbal skills that indicate delayed neurocognitive development.
They may also become irritable, anxious, or depressed, which interferes with the parent– child bonding experience, and they are less assertive and less effectively toilet trained by the age of 5 years.
Currently, more than 55 percent of women are in the workforce, many of whom have no choice but to place their children in daycare centers.
Close to 50 percent of entering medical students are women; few medical centers, however, make adequate provisions for on-site daycare centers for their students or staff.
Similarly, corporations need to provide on-site, high-quality care for the children of their employees.
Not only will that approach benefit the children, but also corporate economic benefits will accrue as a result of reduced absenteeism, increased productivity, and happier working mothers.
Such programs have the added benefit of decreasing stresses on marriages.
Partner Relational Problem
Partner relational problems may include negative communication (e.g., criticisms), distorted communication (e.g., unrealistic expectations), or noncommunication (e.g., withdrawal) associated with clinically significant impairment in individual or family functioning or symptoms in one or both partners.
When persons have partner relational problems, psychiatrists must assess whether a patient’s distress arises from the relationship or a mental disorder.
Mental disorders are more common in single persons—those who never married or who are widowed, separated, or divorced—than among married persons.
Clinicians should evaluate developmental, sexual, occupational and relationship histories, for purposes of diagnosis.
Marriage demands a sustained level of adaptation from both partners.
In a troubled marriage, a therapist can encourage the partners to explore areas such as the extent of communication between the partners, their ways of solving disputes, their attitudes toward childbearing and child-rearing, their relationships with their in-laws, their attitudes toward social life, their handling of finances, and their sexual interaction.
The birth of a child, abortion or miscarriage, economic stresses, moves to new areas, episodes of illness, significant career changes, and any situations that involve a significant change in marital roles can precipitate stressful periods in a relationship.
Illness in a child exerts the most significant strain on a marriage, and marriages in which a child has died through illness or accident more often than not end in divorce.
Complaints of lifelong anorgasmia or impotence by marital partners usually indicate intrapsychic problems, although sexual dissatisfaction is involved in many cases of marital maladjustment.
Adjustment to marital roles can be a problem when partners are from different backgrounds and have grown up with different value systems.
For example, members of low SES groups perceive a wife as making most of the decisions in the family, and they accept physical punishment as a way to discipline children; Middle-class persons perceive family decision-making processes as shared, with the husband often being the final arbiter, and they prefer to discipline children verbally.
Therapists and partners can handle the problems involving conflicts in values, adjustment to new roles, and poor communication by examining the couple’s relationship, as in marital therapy
Epidemiologic surveys show that unhappy marriages are a risk factor for major depressive disorders.
Marital discord also affects physical health. For example, in a study of women age 30 to 65 years with coronary artery disease, marital stress worsened the prognosis 2.9 times for recurrent coronary events.
Marital conflict was also associated with a 46 percent higher relative death risk among female patients having hemodialysis and with elevations in serum epinephrine, norepinephrine, and corticotrophin levels in both men and women.
In one study, patients with high levels of hostile marital behavior had slower healing wounds, lower production of proinflammatory cytokines, and higher cytokine production in peripheral blood.
Overall, women show better psychological and physiologic responsiveness to conflict than men.
Physician Marriages
Physicians have a higher risk of divorce than other occupational groups, around 25-30% of physicians get divorced.
Specialty choice influenced divorce.
The highest rate of divorce occurred in psychiatrists (50 percent) followed by surgeons (33 percent) and internists, pediatricians, and pathologists (31 percent).
The average age at first marriage was 26 years among all groups.
It is not clear why physicians are at high risk for divorce.
Factors implicated include the stresses of dealing with dying patients, making life- and-death decisions, working long hours, and the constant risk of malpractice litigation.
Such stressors may predispose physicians to a variety of emotional ills, with the most common being depression and substance abuse, including alcoholism. Such persons generally cannot deal with the complex interactions required to maintain successful long-term relationships of any kind, and marriage requires the most interpersonal skills of all.
Sibling Relational Problem
Sibling relationships tend to be characterized by competition, comparison, and cooperation.
Intense sibling rivalry can occur with the birth of a child and can persist as the children grow up, compete for parental approval, and measure their accomplishments against one another.
Alliances between siblings are equally common.
Siblings may learn to protect one another against parental control or aggression.
In households with three children, one pair tends to become tightly involved with one another, leaving the extra child in the position of an outsider.
Relational problems can arise when a family treats siblings unequally; for instance, idealizing one child while casting another in the role of the family scapegoat.
Differences in gender roles and expectations expressed by the parents can underlie sibling rivalry.
Parent–child relationships also are dependent on personality interactions.
A child’s resentment directed at a parental figure or a child’s own disavowed dark emotions can be projected onto a sibling and can fuel an intense hate relationship.
An ill child creates stress for the child’s siblings.
Parental concern and attention to the sick child can elicit envy in the siblings. Chronic disability can leave the sick child feeling devalued and rejected by siblings, and the latter may develop a sense of superiority and may feel embarrassed about having a disabled sister or brother.
Twin relationships have become an area of increasing study.
Preliminary data show that twins are more likely to be cooperative than competitive.
Whether or not identical twins should be dressed differently during their toddler years to ensure a separate identity is open to question as is the issue of whether or not they should be in separate classrooms when they begin school.
Other Relational Problems
People, across the life cycle, may become involved in relational problems with leaders and others in their communities at large.
In such relationships, conflicts are frequent and can bring about stress-related symptoms.
Many relational problems of children occur in the school setting and involve peers.
Impaired peer relationships can be the chief complaint in attention-deficit or conduct disorders, as well as in depressive and other psychiatric disorders of childhood, adolescence, and adulthood.
Racial, ethnic, and religious prejudices and ignorance cause problems in interpersonal relationships.
In the workplace and communities at large, sexual harassment is often a combination of inappropriate sexual interactions, inappropriate displays of abuse of power and dominance, and expressions of negative gender stereotypes.
This harassment most often victimizes women and gay men. However, it can also affect children and adolescents of both sexes.