Does the DSM Have Equivalents for the PAS Diagnosis?

Does DSM-IV Have Equivalents for the Parental Alienation Syndrome (PAS) Diagnosis?

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

DSM-IV Diagnoses Related to the Parental Alienation Syndrome

Examiners writing reports for and testifying in courts of law can generally find diagnoses in DSM-IV that are immune to the argument, "It doesn?t exist because it?s not in DSM-IV." These diagnoses are not identical to the PAS, but they have common elements that can justify their utilization. None of them, however, are identical to the PAS and cannot be used as substitutes for it. I present here those that are most applicable and potentially useful in courts of law.

Diagnoses Applicable to Both Alienating Parents and PAS Childrem

297.3 Shared Psychotic Disorder


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

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-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

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


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:

> suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

> is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

> is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

> reads hidden demeaning or threatening meanings into benign remarks or events

> persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

> perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

> 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:

> frantic efforts to avoid real or imagined abandonment.
Note:Do not include suicidal or self-mutilating behavior covered in Criterion 5.

> a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

> identity disturbance: markedly and persistently unstable self-image or sense of self

> 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.

> recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

> 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)

> chronic feelings of emptiness

> inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

> 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."

301.81 Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

> has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements

> is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

> believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

> requires excessive admiration

> has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

> is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

> lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

> is often envious of others or believes that others are envious of him or her

> shows arrogant, haughty behaviors or attitudes

My experience has been that most PAS indoctrinators do not satisfy enough criteria (five) to warrant this diagnosis. However, many do exhibit three or four of them, which is worthy of the examiner?s attention and should be noted in the report.

Criterion (5) is especially common in PAS indoctrinators. They act as if court orders have absolutely nothing to do with them, even though their names may be specifically spelled out in the ruling. Unfortunately, they often violate these orders with impunity because courts are typically lax with regard to implementing punitive measures for PAS contemnors. As mentioned in other publications of mine (Gardner, 1998; 2001), the failure of courts to take action against PAS programmers is one of the most common reasons why the symptoms become entrenched in the children.

Criterion (6) is often frequently satisfied by the programmer?s ongoing attempts to extract ever more money from the victim parent, but feels little need to allow access to the children. There is no sense of shame or guilt over this common form of exploitation. The programmer?s lack of empathy and sympathy for the victim parent is quite common and easily satisfies Criterion (7). The PAS, by definition, is a disorder in which a programmer tries to destroy the bond between the children and a good, loving parent. In order to accomplish the goal, the alienator must have a serious deficiency in the ability to empathize with the target parent. Criterion (9) is often seen in that PAS indoctrinators are often haughty and arrogant and this symptom goes along with their sense of entitlement. Again, if warranted, the diagnosis can be listed as "incipient."

DSM-IV Diagnoses Applicable to PAS Children

312.8 Conduct Disorder

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

This diagnosis is often applicable to the PAS child, especially in situations when the conduct disturbances are the most salient manifestation. Under such circumstances, an examiner who is not familiar with the PAS may erroneously conclude that this is the only diagnosis. Such a conclusion necessitates selective inattention to the programming process, which is the hallmark of the PAS. Once again, we see here how a diagnosis, although in DSM-IV, cannot be used as a substitute for the PAS, but may be used as an additional diagnosis. I will not list here all 15 of the DSM-IV criteria, but only those that are most applicable to the PAS:

Aggression to people and animals

> often bullies, threatens, or intimidates others

> often initiates physical fights

> has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

> has been physically cruel to animals

> has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

Destruction of property

> has deliberately engaged in fire setting with the intention of causing serious damage

> has deliberately destroyed others? property (other than by fire setting)

Deceitfulness or theft

> often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)

> has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

> has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period

As can be seen, most of the 15 criteria for the conduct disorder diagnosis can be satisfied by PAS children, especially those in the severe category. The target parent is very much scapegoated and victimized by PAS children. In severe cases they are screamed at, intimidated, and sometimes physically assaulted with objects such as bats, bottles, and knives. The child may perpetrate acts of sabotage in the home of the victim parent. Destruction of property in that person?s home is common and, on rare occasion, even fire setting. Deceitfulness is common, especially fabrications facilitated and supported by the alienator. Stealing things, such as legal documents and important records, and bringing them to the home of the alienator is common. Running away from the home of the target parent and returning to the home of the alienator is common, especially in moderate and severe cases.

309.21 Separation Anxiety Disorder

Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

I reproduce here those of the eight criteria that are applicable to the PAS:

1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation

8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

It is important for the reader to appreciate that the original diagnosis for separation anxiety disorder was school phobia. The term separation anxiety disorder is a relatively recent development emerging from the recognition that the child?s fear was less that of the school per se and much more related to the fear of separation from a parent, commonly an overprotective mother (Gardner, 1985b). DSM-IV recognizes this and doesn?t necessarily require the school to be the object of fear, but rather separation from the home, especially from someone with whom the child is pathologically attached.

It is important to note that the PAS child?s hatred of the victim parent has less to do with actual dislike of that parent and has much more to do with fear that if affection is displayed toward the target parent, the alienating parent will be angry at and rejecting of the child. At the prospect of going with the victim parent, the child may exhibit a wide variety of psychosomatic symptoms, all manifestations of the tension associated with the visit. The distress may be especially apparent when the alienating parent is at the site of the transfer. The child recognizes that expression of willingness or happiness to go off with the alienated parent might result in rejection by the alienator. The separation anxiety disorder diagnosis is most often applicable to the mild and moderate cases of PAS. In the severe cases, the anxiety element is less operative than the anger element.

When applying these criteria to the PAS child, one does well to substitute the PAS indoctrinating parent for the parent with whom the child is pathologically attached. At the same time one should substitute the alienated parent for the school or other place outside the child?s home. When one does this, one can see how most of the aforementioned criteria apply. When the child with a separation anxiety disorder is fearful of leaving the home to go to many destinations, the school is the destination the child most fears. It is there that the child feels imprisoned. In contrast, PAS children generally fear only the target parent and are not afraid to leave the programming parent and go elsewhere, such as to the homes of friends and relatives. In short, the PAS child?s fear is focused on the alienated parent. In contrast, the child with a separation anxiety disorder has fears that focus on school but which have spread to many other situations and destinations.

300.15 Dissociative Disorder
Not Otherwise Specified

This category is included for disorders in which the predominant feature is a dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific Dissociative Disorder. Examples include:

States of dissociation that occur in individuals who have been subjected to periods of prolonged and coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive).

Of the four categories of dissociative disorder (NOS), only Category 3 is applicable to the PAS. This criterion was designed for people who have been subjected to cult indoctrinations or for military prisoners subjected to brainwashing designed to convert their loyalty from their homeland to the enemy that has imprisoned them. It is very applicable to PAS children, especially those in the severe category. Such children have been programmed to convert their loyalty from a loving parent to the brainwashing parent exclusively. Cult victims and those subjected to prisoner indoctrinations often appear to be in a trance-like state in which they profess their indoctrinations in litany-like fashion. PAS children as well (especially those in the severe category) are often like robots or automatons in the way in which they profess the campaign of denigration in litany-like fashion. They seem to be in an altered state of consciousness when doing so.

Adjustment Disorders

The following subtypes of adjustment disorders are sometimes applicable to PAS children:

309.0 With Depressed Mood.

309.24 With Anxiety.

309.28 With Mixed Anxiety and Depressed Mood.

309.3 With Disturbance of Conduct.

309.4 With Mixed Disturbance of Emotions and Conduct

Each of these types of adjustment disorders may be applicable to the PAS child. The child is indeed adjusting to a situation in which one parent is trying to convince the youngster that a previously loving, dedicated, and loyal parent has really been noxious, loathsome, and dangerous. The programmed data does not seem to coincide with what the child has experienced. This produces confusion. The child fears that any expression of affection for the target parent will result in rejection by the alienator. Under such circumstances, the child may respond with anxiety, depression, and disturbances of conduct.

313.9 Disorder of Infancy, Childhood or Adolescence Not Otherwise Specified

This category is a residual category for disorders with onset in infancy, childhood, or adolescence that do not meet criteria for any specific order in the Classification.

This would be a "last resort" diagnosis for the PAS child, the child who, although suffering with a PAS, does not have symptoms that warrant other DSM-IV childhood diagnoses. However, if one still feels the need to use a DSM-IV diagnosis, especially if the report will be compromised without one, then this last-resort diagnosis can justifiably be utilized. However, it is so vague that it says absolutely nothing other than that the person who is suffering with this disorder is a child. I do not recommend its utilization because of its weakness and because it provides practically no new information to the court.

DSM-IV Diagnoses Applicable to Alienated Parents

In most PAS cases, a diagnosis is not warranted for the alienated parent. On occasion that parent does warrant a DSM-IV diagnosis, but its applicability usually antedated the separation and usually has not played a role in the PAS development or promulgation. As mentioned elsewhere (Gardner, 2001), the primary problem I have seen with alienated parents is their passivity. They are afraid to implement traditional disciplinary and punitive measures with their children, lest they alienate them even further. And they are afraid to criticize the alienator because of the risk that such criticism will be reported to the court and compromise even further their position in the child-custody litigation. Generally, their passivity is not so deep-seated that they would warrant DSM-IV diagnoses such as avoidant personality disorder (301.82) or dependent personality disorder (301.6), because such passivity does not extend into other areas of life and did not antedate the marital separation. One could argue that they have an adjustment disorder, but there is no DSM diagnosis called "adjustment disorder, with passivity." Accordingly, I will often state for alienated parents, "No Axis 1 diagnosis."

If, indeed, the alienated parent did suffer with a psychiatric disorder that contributed to the alienation, then this should be noted. Certainly, there are situations in which the alienated parent?s psychiatric disorder is so profound that it is the primary cause of the children?s alienation. In such cases, the PAS diagnosis is not warranted. Under such circumstances, this disorder should be described instead as the cause of the children?s alienation.

Final Comments About Alternative DSM-IV Diagnoses for the PAS

As mentioned, the primary reason for using these diagnoses is that the PAS, at this point, is not recognized in some courts of law. They cannot be used as substitute diagnoses for the PAS, but sometimes share in common some of the symptoms. Accordingly, they can be used as additional diagnoses. It is too early to expect widespread recognition because it was not feasible for the PAS to have been placed in the 1994 edition, so few were the publications on the disorder when the preparatory committees were meeting. This will certainly not be the case when the committees meet in the next few years for the preparation of DSM-V, which is scheduled for publication in 2010. None of the aforementioned substitute diagnoses are fully applicable to the PAS; however, as mentioned, each one has certain characteristics which overlap the PAS diagnosis. Because no combination of these alternative diagnoses can properly replace the PAS, they should be used in addition to rather than instead of the PAS. There is hardly a diagnosis in DSM-IV that does not share symptoms in common with other diagnoses. There is significant overlap and often fluidity in DSM diagnoses. None are "pure," but some are purer than others, and the PAS is one of the purer ones.

At this point, examiners who conclude that PAS is an applicable diagnosis do well to list it in the appropriate place(s) in their reports (especially at the end). At the same time, they do well to list any DSM-IV diagnoses that are applicable for the alienator, the alienated child, and (if warranted) for the alienated parent. Accordingly, even if the court will not recognize the PAS diagnosis, it will have a more difficult time ignoring these alternative DSM diagnoses.

Conclusions

Controversies are likely when a new disorder is first described. This is predictable. The PAS, however, has probably generated more controversy than most new diagnostic contributions. The primary reason for this is that the PAS is very much a product of the adversary legal system that adjudicates child-custody disputes. Under such circumstances, it behooves opposing attorneys to discredit the contribution and to find every argument possible for obstructing its admission into courts of law. And this is what happened with the PAS. The purpose of this article has been to help evaluators involved in such disputes understand better the nature of the controversy and to deal with it in the context of the present legal situation. Like all compromises, the solution is not perfect. None of the additional diagnoses are identical to the PAS, but they do serve a purpose in a court of law in that they are established psychiatric diagnoses that are applicable to PAS alienators, PAS children, and (on occasion) the alienated parent. Ultimately, if PAS is admitted into DSM-V, the main argument for its inadmissibility in courts of law will no longer be applicable and the need for listing these additional diagnoses in courts of law will be reduced.

References

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-IV). Washington, D.C.: American Psychiatric Association.

Boyd v. Kilgore, 773 So. 2d 546 (Fla. 3d DCA 2000) (Prohibition Denied)

Kilgore v. Boyd, 13th Circuit Court, Hillsborough County, FL., Case No. 94-7573, 733 So. 2d 546 (Fla. 2d DCA 2000) Jan 30, 2001

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_______ (2002), Parental alienation syndrome vs. parental alienation: Which diagnosis should be used in child-custody litigation? The American Journal of Family Therapy, 30(2):101-123.

rgardner.com, Articles in Peer-reviewed journals and Published Books on the Parental Alienation Syndrome (PAS). www.rgardner.com/refs

_______, Testimony Concerning the Parental Alienation Syndrome Has Been Admitted in Courts of Law in Many States and Countries. www.rgardner.com/refs

Warshak, R. A. (1999), Psychological syndromes: Parental alienation syndrome. Expert Witness Manual, Chapter 3-32. Dallas, TX:State Bar of Texas, Family Law Section.

_______ (2001), Current controversies regarding parental alienation syndrome. The American Journal of Forensic Psychology, 19(3):29-59.

?2002 Richard A. Gardner, M.D.

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