Max Littman, LCSW

February 21, 2025

For those of us who practice IFS, the DSM, which is treated as the cornerstone of traditional mental health diagnostics, can feel mechanistic and reductionist. But when we step back and view its diagnoses through an IFS framework, a rich, multidimensional picture emerges: one of systems, burdens, and parts working hard to keep people functioning in the face of profound pain and unmet needs. Let’s take a tour through some major DSM diagnoses, understanding symptoms as expressions of parts and burdens so that we might bridge the gap between humanistic, compassionate, non-pathologizing, ethical, and effective care and the realities of the health care system in which we are embedded.

Anxiety Disorders: Hypervigilant Managers

Anxiety disorders, such as Generalized Anxiety Disorder (GAD) and Panic Disorder, are often dominated by manager parts. These parts work overtime to anticipate and prevent perceived threats, driven by an underlying belief that vigilance is the only way to ensure safety. For example:

  • GAD:
    • Excessive anxiety and worry: Manager parts engage in constant scanning and planning to preempt threats.
    • Difficulty controlling the worry: Managers feel overwhelmed by the scope of their protective efforts.
    • Physical symptoms (e.g., restlessness, fatigue, muscle tension): These reflect the toll of prolonged hypervigilance.
  • Panic Disorder:
    • Recurrent, unexpected panic attacks: Firefighters act abruptly when managers’ strategies fail, triggering intense physical and emotional reactions.
    • Persistent concern about additional attacks: Managers adopt heightened vigilance to prevent future disruptions.
    • Maladaptive behavioral changes (e.g., avoiding triggers): Managers and firefighters collaborate to shield the system from potential panic-inducing situations.

Depressive Disorders: Weary Managers and Firefighters

Depression often emerges when managers feel they’ve failed or when firefighter strategies backfire. Parts burdened with hopelessness or worthlessness take center stage, sometimes in an attempt to protect exiles from overwhelming pain.

  • Major Depressive Disorder (MDD):
    • Depressed mood most of the day: Exiles carry burdens of sadness and shame, flooding the system.
    • Diminished interest or pleasure: Managers enforce withdrawal to minimize emotional risk.
    • Fatigue or loss of energy: The system’s parts feel depleted by prolonged efforts to manage burdens.
    • Feelings of worthlessness or guilt: Exiles carry deep burdens, while managers amplify self-criticism to motivate or control.
  • Persistent Depressive Disorder (PDD):
    • Chronic low mood: A long-standing dynamic where exiles’ burdens remain unaddressed.
    • Feelings of hopelessness: Managers’ and firefighters’ efforts feel futile after prolonged attempts to shield the system.

Trauma- and Stressor-Related Disorders: Overwhelmed Systems

Trauma impacts the system profoundly, leaving exiles carrying burdens of fear, shame, and terror. Managers and firefighters often adopt extreme strategies to contain or distract from this pain.

  • PTSD:
    • Intrusive memories: Exiles attempt to share their pain but overwhelm the system.
    • Avoidance of reminders: Managers shield exiles by steering the system away from triggers.
    • Hyperarousal (e.g., irritability, startle response): Managers remain on high alert to prevent further harm.
  • Complex PTSD:
    • Emotional dysregulation: Polarized parts struggle to maintain balance, with frequent shifts between extreme states.
    • Negative self-concept: Exiles carry burdens of worthlessness, reinforced by managers’ self-critical narratives.
    • Interpersonal difficulties: Parts struggle to trust or connect due to past relational trauma.

Dissociative Disorders: Fragmented Systems

Dissociative disorders reveal systems where parts have become fragmented to shield exiles from overwhelming trauma. The system’s response is one of compartmentalization, often leading to distinct and disconnected inner dynamics.

  • Dissociative Identity Disorder (DID):
    • Two or more distinct personality states: Parts operate independently, often unaware of one another, to protect the system from unbearable memories or feelings.
    • Amnesia for daily events or trauma: Managers enforce dissociation to maintain functioning and avoid triggering exiles.
  • Dissociative Amnesia:
    • Inability to recall important personal information: Managers block access to painful memories held by exiles.
  • Depersonalization/Derealization Disorder:
    • Feelings of detachment from self or reality: Firefighters create a sense of unreality to buffer the system from emotional pain or overwhelm.

Obsessive-Compulsive Disorder: Controlling Managers

In OCD, manager parts take on rigid, repetitive strategies to prevent catastrophe and control chaos. These parts often believe their efforts are the only thing standing between the system and disaster.

  • Obsessions:
    • Recurrent, intrusive thoughts: Exiles’ burdens of fear or shame leak through the system.
    • Attempts to ignore or suppress thoughts: Managers exert control to contain these perceived threats.
  • Compulsions:
    • Repetitive behaviors or mental acts: Managers implement rituals to neutralize perceived dangers.
    • Time-consuming and distressing: The rigidity of these strategies strains the system and isolates the client.

Personality Disorders: Burdened Systems

Personality disorders often reflect systems that have endured profound, prolonged pain. Parts take on extreme roles to protect the system or navigate unsafe environments.

  • Borderline Personality Disorder (BPD):
    • Frantic efforts to avoid abandonment: Manager and firefighter parts oscillate between intense connection-seeking and protective withdrawal.
    • Unstable relationships: Polarized parts react to relational triggers, alternating between idealization and devaluation.
    • Chronic feelings of emptiness: Exiles’ unmet needs remain unaddressed, leaving the system in despair.
  • Narcissistic Personality Disorder (NPD):
    • Grandiosity: Manager parts construct an inflated self-image to shield exiles burdened with inadequacy.
    • Need for admiration: Managers seek external validation to stabilize the system.
    • Lack of empathy: Firefighters protect exiles by dismissing others’ emotions.

Substance-Related and Addictive Disorders: Firefighter Strategies

Substance use often reflects firefighter parts working to soothe or distract the system from unbearable pain. These parts may view substances as the only effective tool for survival.

  • Alcohol Use Disorder:
    • Inability to control use: Firefighters feel compelled to rely on alcohol as a coping mechanism.
    • Craving and preoccupation: Managers and firefighters focus on obtaining relief from burdens.
    • Continued use despite consequences: Firefighters persist, believing no other strategy will alleviate the pain.
  • Behavioral Addictions:
    • Compulsive engagement in behaviors: Firefighters find temporary relief in activities like gambling or shopping.
    • Inability to stop: Managers struggle to rein in firefighter strategies, fearing the exiles’ overwhelm.

Eating Disorders: Managers and Firefighters at Odds

Eating disorders often involve polarized parts: managers striving for control and firefighters seeking relief from unbearable emotions.

  • Anorexia Nervosa:
    • Restriction of food intake: Managers enforce rigid control to suppress exiles’ feelings of inadequacy.
    • Intense fear of gaining weight: Managers overcompensate to shield against perceived threats of rejection.
  • Bulimia Nervosa:
    • Binge eating episodes: Firefighters use food to soothe emotional overwhelm.
    • Compensatory behaviors (e.g., purging): Managers act swiftly to restore a sense of control.

Bipolar and Related Disorders: Polarized Systems

Bipolar disorder illustrates extreme polarization within the system.

  • Manic Episodes:
    • Elevated or irritable mood: Managers push for heightened activity to drown out exiles’ burdens.
    • Impulsivity: Firefighters act recklessly to escape emotional pain or restriction.
  • Depressive Episodes:
    • Low energy and hopelessness: Exiles’ burdens flood the system with despair, overwhelming protective parts.

Neurodevelopmental Disorders: Parts Adapting to Difference

Conditions like ADHD and Autism Spectrum Disorder reflect systems navigating neurological differences in a world that often lacks accommodation.

  • ADHD:
    • Inattention: Managers struggle to maintain focus amid internal and external distractions.
    • Hyperactivity: Firefighters discharge excess energy to cope with overwhelm.
  • Autism Spectrum Disorder:
    • Difficulty with social interaction: Manager parts may struggle to interpret social cues, leading to withdrawal.
    • Restricted or repetitive behaviors: Managers create predictability and order to soothe the system.

Schizophrenia and Related Disorders: Permeable Systems

Schizophrenia offers a unique condition for understanding how parts and systems interact when boundaries within the system are porous and disorganized. This disorder often reflects a system unprotected from outside energies and overwhelmed by burdens it cannot metabolize.

  • Positive Symptoms (e.g., hallucinations, delusions):
    • These may emerge from parts attempting to make sense of overwhelming internal or external stimuli, often drawing on symbolic or fragmented narratives.
    • In cases of hallucinations, parts may externalize inner burdens or energies, amplifying their voices as though they are outside the system.
  • Negative Symptoms (e.g., reduced emotional expression, social withdrawal):
    • Managers withdraw to minimize further disruption, leaving the system in a muted state.
    • Exiles’ burdens of disconnection and isolation surface when protective parts step back.
  • Disorganized Symptoms (e.g., incoherent speech, erratic behavior):
    • The system’s permeability allows external energies to infiltrate, creating confusion and disarray among parts.
    • As Robert Falconer explores in The Others Within Us, this permeability may connect to a concept of “porous mind,” where parts struggle to differentiate between internal and external influences.
    • Falconer’s work invites us to consider how “others within”—energies or entities that feel distinct from the self—interact with an already burdened system, further complicating efforts toward coherence.

Closing Thoughts

Reframing DSM diagnoses through an IFS lens invites compassion for the intricate systems within our clients. It shifts the focus from “disorder” to an appreciation of the interplay between parts and burdens in navigating life’s challenges. By attuning to these parts and their protective roles, we can help clients unburden and experience a better balance of parts and Self.

For feedback and comments, I can be reached at max@maxlittman.com.

I provide private practice mentorship, consultation, and therapist/practitioner part intensives.

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References

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  • Schwartz, R. C. (1995). Internal Family Systems Therapy. New York: Guilford Press.
  • Falconer, R. (2023). The Others Within Us: Internal Family Systems, Porous Mind, and Spirit Possession. Great Mystery Press.
  • Fisher, J. (2017). Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self-Alienation. New York: Routledge.
  • Van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking.
  • Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York: Norton.