Resorting the DSM by Function
Re-Sorting the DSM
Adaptation, Not Malfunction
Companion handout — “On Being a Systemic Clinician”
Dr. Quintin A. Hunt, Ph.D., LMFT · Olive View Institute · oliveviewtherapy.com
If we take every disorder in the DSM and ask a single question — is this primarily biological, or an adaptation to a pattern of stressor? — most of the manual resolves into a catalog of adaptations being misread as malfunctions. The DSM sorts by symptom. A systemic clinician sorts by context and function: what is this doing, and what did it once solve?
Part I — Biological or Adaptive?
Category A — Primarily Biological
Strong genetic, neuroanatomical, or neurodevelopmental evidence that exists largely independent of relational context. The stressor doesn’t create the condition — the biology does.
● Neurodevelopmental (structural / genetic): autism spectrum disorder, intellectual disabilities, specific learning disorders (dyslexia, dyscalculia), communication disorders (stuttering, language disorder), Tourette’s / tic disorders.
● Psychotic spectrum: schizophrenia, schizoaffective disorder, delusional disorder. Onset may be stress-triggered, but the underlying architecture — dopamine dysregulation, cortical thinning — is biological.
● Neurocognitive: Alzheimer’s, vascular dementia, Parkinson’s-related cognitive decline, TBI-related neurocognitive disorder, Huntington’s. These are tissue-level.
● Other: narcolepsy (orexin deficiency) and some genetic syndromes captured in DSM coding.
Category B — Adaptations to a Pattern of Stressor
Better understood as the system’s intelligent response to a context — the organism doing exactly what makes sense given the relational field it’s embedded in. The DSM names them disorders; a systemic clinician sees them as solutions.
● Trauma and stress responses: PTSD, complex PTSD, acute stress disorder, adjustment disorders, reactive attachment disorder, disinhibited social engagement disorder. Almost definitionally adaptive — the DSM itself requires a stressor.
● Dissociative disorders: DID, dissociative amnesia, depersonalization / derealization. Among the most elegant adaptations in the manual — the system learns to leave when it can’t physically leave. That’s not dysfunction. That’s engineering.
● Personality disorders — all of them: borderline (adaptation to chronic invalidation and attachment disruption), avoidant (to rejection), dependent (to a system that punished autonomy), narcissistic (to conditional worth), antisocial (to an environment where trust was correctly identified as dangerous). The personality isn’t disordered — it was precisely ordered to survive a specific relational field.
● Depressive disorders: major depression, persistent depressive disorder. Withdrawal when the environment has been reliably unresponsive or punishing. Learned-helplessness research supports this directly.
● Most anxiety disorders: generalized anxiety, social anxiety, specific phobias, agoraphobia, separation anxiety. The system learned the world is dangerous because for that person, it was. The hypervigilance is calibrated to a real history.
● Eating disorders: anorexia, bulimia, binge eating disorder. Control of the body when the relational environment is uncontrollable. The symptom makes sense inside the system.
● Substance use disorders: self-medication for pain the system couldn’t otherwise metabolize. Maté’s line applies: not “why the addiction?” but “why the pain?”
● Oppositional defiant / conduct disorder: a child who “won’t listen” in a system that never listened to them. The defiance is the communication.
● Somatic symptom disorders: the body speaks what the relational system won’t let the mouth say.
● Many sexual dysfunctions: desire, arousal, and pain disorders that track to relational dynamics, attachment history, or trauma — not plumbing.
● Insomnia and many sleep-wake disorders: hyperarousal in a system that taught the organism it isn’t safe to let its guard down.
The Gray Zone
Real biological substrates, but the clinical trajectory — whether they become “disorders” or manageable differences — is determined by relational context. This is where backward causation as a clinical concept does its heaviest work.
● ADHD: the dopamine system is genuinely different. But whether that difference becomes a disorder depends entirely on the system’s response. A child with ADHD in a classroom built for compliance is disordered; the same child in a context that accommodates novelty-seeking is gifted. The biology is real. The pathology is relational. The diagnosis is an observer effect.
● Bipolar disorder: strong heritability, lithium responsiveness, a clear neurobiological signature. But episodes are often triggered by relational stress, sleep disruption, or loss. The biology loads the gun; the system pulls the trigger — and how the family responds shapes whether the trajectory is stabilization or escalation (expressed-emotion research).
● OCD: cortico-striato-thalamic circuit dysfunction is well-documented, but the content of obsessions and the onset often track to relational stressors. In a validating system that accommodates exposure work, OCD looks very different than in one that reinforces avoidance. The loop is biological; whether it runs the person’s life is systemic.
● Panic disorder: the autonomic cascade is real physiology. But the fear of the fear — the agoraphobic avoidance that turns panic into a life-limiting condition — is an adaptation to a context where no one taught the person that the sensations were survivable.
The Meta-Point
Even Category A isn’t immune. A person with schizophrenia in a high-expressed-emotion family relapses at roughly four times the rate of one in a low-EE family (Butzlaff & Hooley, 1998). The biology is biological — but the course of the illness, the thing that determines quality of life, is relational. The system doesn’t cause schizophrenia; it determines what schizophrenia becomes.
This loops back to backward causation: the family’s response to the diagnosis retroactively constitutes what the diagnosis is. A family that treats autism as tragedy produces a different developmental trajectory than one that treats it as difference. The biology hasn’t changed. The observer has — and the observation doesn’t just describe the system, it enters it.
So the honest answer: Category A is much smaller than the DSM implies, Category B is much larger, and even the disorders that belong in Category A have their clinical meaning determined by Category B dynamics. Sort by context, and most of the manual dissolves into a catalog of adaptations being misread as malfunctions.
Part II — B1 & B2: The Direction of the Adaptation
Once a symptom is understood as an adaptation, the next question is which way it points. Every adaptation in Category B organizes around a single variable: control. Faced with an intolerable system, the organism either moves to seize control and responsibility, or moves to shed them. That direction — not the symptom label — is what tells you how to intervene.
B1 — Gain Control / Seize Responsibility
Safety comes from managing everything: monitor, restrict, anticipate, dominate. The B1 client has concluded that vigilance is the price of survival. Their nervous system is switched on.
● OCD — rituals impose order on a chaotic or dangerous environment
● Anorexia nervosa — restriction as sovereignty when the relational world feels uncontrollable
● Generalized anxiety — worry as anticipatory control; hypervigilance as a full-time job
● ODD / Conduct — seizing the agency the system refused to grant
● Narcissistic PD — controlling perception; grandiosity built over worthlessness
● Antisocial PD — control through force or manipulation; never be the one without leverage
● Obsessive-compulsive PD — becoming the rule-maker when the environment had no reliable rules
● Paranoid PD — hypervigilant monitoring; trust is dangerous
● PTSD (hyperarousal cluster) — startle, scanning, insomnia; the system stays switched on
● Panic (monitoring phase) — full-time body-scanning to control the next attack
B2 — Escape Control / Shed Responsibility
Engagement is dangerous or futile: withdraw, go offline, refuse the game. The B2 client has concluded that effort doesn’t change outcomes, so the safest move is to stop trying. Their nervous system is switched off.
● Dissociative disorders (DID, amnesia, depersonalization / derealization) — the mind leaves when the body can’t
● Major / persistent depressive disorder — shutdown when the environment is reliably unresponsive (learned helplessness)
● Substance use disorders — escape from awareness, pain, and the demands of presence
● Avoidant PD — preemptive removal from the field to escape rejection
● Dependent PD — outsourcing every decision — “I can’t get it wrong if I never choose”
● Social anxiety — escape from evaluation; being seen is being judged
● Agoraphobia — the world shrinks to what feels safe
● Specific phobias — focal escape; diffuse anxiety channeled into one avoidable stimulus
● PTSD (avoidance / numbing cluster) — emotional flattening, constricted life
● Conversion / functional neurological — the body shuts down a function
● Binge eating — food as a numbing or dissociative vehicle
● Selective mutism — the voice escapes; speaking requires unsafe engagement
The Oscillators—B1 ⇄ B2
The most complex presentations: the adaptive strategy keeps reversing. What looks like “comorbidity” is often one organism switching direction.
● Borderline PD — clinging / testing (B1) → self-harm / dissociation (B2), often within the hour
● Bulimia — binge (B2) → purge (B1); the disorder is the oscillation itself
● PTSD as a whole — hyperarousal (B1) alternating with avoidance and numbing (B2)
● Bipolar — mania (B1 extreme) → depression (B2 withdrawal)
● RAD vs. DSED — same stressor, opposite direction — withdrawal vs. indiscriminate approach
Why Direction Changes the Treatment
● A B1 client — doesn’t need more coping skills — that’s more to control. They need permission to release, and a system safe enough that letting go doesn’t feel like death.
● A B2 client — doesn’t need to be told to “engage more” or “try harder.” They need the system to become safe enough that engagement is no longer a threat worth escaping.
● Naming the direction — retroactively reconstitutes the symptom: the ritual stops being irrational and becomes the most rational move the system could make. The reframe doesn’t change the behavior — it changes what the behavior was.
● Good enough beats optimal — a symptom is the first adequate fix that out-competed doing nothing. A better solution only wins if it beats the incumbent AND the system’s homeostatic pull toward the status quo. You reorganize the field, not the person.
References
American Psychiatric Association (2022). DSM-5-TR. APA Publishing.
Barkley, R. A. (2015). ADHD: A Handbook for Diagnosis and Treatment (4th ed.). Guilford.
Bateson, G. (1972). Steps to an Ecology of Mind. University of Chicago Press.
Bowen, M. (1978). Family Therapy in Clinical Practice. Jason Aronson.
Butzlaff, R. L. & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse. Archives of General Psychiatry, 55(6), 547–552.
Cannon, W. B. (1932). The Wisdom of the Body. W. W. Norton.
de Catanzaro, D. (1991). Ethology and Sociobiology, 12(1), 13–28.
Faraone, S. V. et al. (2006). Psychological Medicine, 36(2), 159–165.
Foa, E. B. & Kozak, M. J. (1986). Psychological Bulletin, 99(1), 20–35.
Hamilton, W. D. (1964). Journal of Theoretical Biology, 7(1), 1–52.
Joiner, T. E. (2005). Why People Die by Suicide. Harvard University Press.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford.
Maté, G. (2008). In the Realm of Hungry Ghosts. Knopf Canada.
McGoldrick, M. et al. (2020). Genograms (4th ed.). W. W. Norton.
Nesse, R. M. (2019). Good Reasons for Bad Feelings. Dutton.
Seligman, M. E. P. (1975). Helplessness: On Depression, Development, and Death. W. H. Freeman.
von Bertalanffy, L. (1968). General System Theory. George Braziller.