Levels of Personality Organization

The Continuum

Level of organization is a continuum, not four boxes. McWilliams describes the developmental axis as divided into three main categories but “actually a continuum,” with differences of degree that become large enough to be talked about as differences of kind (McWilliams, 2011, p. 95). The PDM-3 adds that the levels “lack clearly demarcated boundaries” (McWilliams & Shedler, 2026, p. 661), and the Psychodiagnostic Chart (PDC-3) that operationalizes the PDM reminds raters that there are no sharp cutoffs between categories (Gordon & Bornstein, 2025).

At the healthy end, the PDM-3 describes people who can engage in satisfying relationships, experience a relatively full range of feelings and thoughts, function flexibly when stressed, keep a coherent sense of identity, regulate impulses to fit the situation, live by internalized values, and neither suffer undue distress nor impose it on others. At the severely disturbed end are people who respond to distress in rigidly inflexible ways or who have major deficits in basic mental capacities such as affect regulation or the capacity to understand minds (McWilliams & Shedler, 2026, pp. 654–655).

Everyone moves along this line to some degree. McWilliams writes that we can all find in ourselves issues from every level (2011, p. 56), that under enough stress an optimally healthy person can have a temporary psychotic reaction, and that even a person with severe delusions has moments of complete lucidity (p. 95). What a level describes is where a person’s functioning tends to settle, especially when life gets hard.

In her summary of the traditional view, McWilliams characterizes the three classic regions (psychotic, borderline, neurotic) by a set of contrasts (2011, p. 68):

• Central preoccupation: security, autonomy, or identity.
• Characteristic anxiety: annihilation anxiety, separation anxiety, or more specific fears of punishment, injury, and loss of control.
• Primary developmental conflict: symbiotic, separation–individuation, or oedipal (that is, conflicts within a three-person world of love, rivalry, and guilt).
• Object relations: monadic, dyadic, or triadic.
• Sense of self: overwhelmed, embattled, or responsible.

The healthy level, which the PDM treats separately, sits above all three: the same capacities, well developed and generally reliable (McWilliams & Shedler, 2026, p. 657).

Two Dimensions: Style and Level

The PDM-3 states that level of organization “crosscuts” personality style: any style can, in principle, exist at any level. A person with a narcissistic style at a high level may be a leader or visionary; the same style at a low level may be dysfunctional in many areas of life (McWilliams & Shedler, 2026, p. 652). McWilliams draws the two dimensions as axes on a single figure, with types running across and the developmental continuum running from psychotic to neurotic–healthy (2011, pp. 95–96).

She gives a striking illustration of why both are needed. Three women with the same phobia can be very different: one seems to be clinging to sanity by a thread, another is oddly stable in her instability, and the third is, apart from the phobia, a model of mental health (McWilliams, 2011, p. 54). The symptom is the same; the level is not.

People are not spread evenly across the grid. Styles built on more primitive defenses “load” toward the more disturbed end, and styles built on more mature defenses load toward the healthier end (McWilliams, 2011, p. 96). The PDM-3 gives examples: people with hysterical or obsessional styles are more often organized at a healthy or neurotic level, while those with paranoid or psychopathic styles are more often organized at a borderline or psychotic level (McWilliams & Shedler, 2026, p. 655). The exceptions are instructive. McWilliams points to people with a distinctly paranoid personality who nonetheless have good ego strength, a consolidated identity, and lasting relationships, sometimes in work where vigilance is an asset, and to people who rely on a “mature” defense like intellectualization whose thinking has crossed into delusion (2011, p. 97).

Two further patterns follow. First, healthier people rarely fit one pure type, because flexibility of defense is part of health; “purer” examples of a style are generally seen at lower levels (McWilliams, 2011, p. 97; McWilliams & Shedler, 2026, p. 665). Second, one style is tied to a level by definition: the PDM-3’s emotionally dysregulated personality (its new name for what the DSM calls borderline personality disorder) is necessarily linked to the borderline level (p. 665).

McWilliams adds that it is often more important clinically to have a sense of a person’s overall level than to identify the most fitting style (2011, p. 97). Level shapes what kind of help is likely to be useful; style shapes how that help should be offered.

What Clinicians Look At

Following Otto Kernberg’s model, the PDM identifies and differentiates the levels by degree of identity integration versus diffusion, reliance on primitive versus mature defenses, and adequacy of reality testing, and it adds the quality of object relations (McWilliams & Shedler, 2026, p. 655; Tanzilli & Sharp, 2026, p. 479). The PDC-3 turns these into four ratings, each scored from 1 (severely impaired) to 10 (healthy), followed by an overall judgment (Gordon & Bornstein, 2025).

Identity

The ability to see oneself in complex, stable, and accurate ways. At healthier levels people can describe their temperament, values, tastes, and shortcomings with a sense of continuity over time, and they describe others as multifaceted people. At the borderline level, descriptions of self and others tend to be global and dismissive; at the psychotic level they may be vague, concrete, or visibly distorted (McWilliams, 2011, pp. 57, 60, 64).

Object relations

The ability to keep intimate, stable, and satisfying relationships, and to hold an inner picture of other people as whole and separate. “Object relations” is the psychoanalytic term for the inner images of self and others that shape how we relate.

Defenses

The PDC-3 anchors its defense rating to the level: delusional projection, psychotic denial, and psychotic distortion at 1–2; splitting, projective identification, idealization and devaluation, denial, and acting out at 3–5; repression, reaction formation, intellectualization, displacement, and undoing at 6–8; and anticipation, self-assertion, sublimation, suppression, altruism, and humor at 9–10 (Gordon & Bornstein, 2025). McWilliams adds a useful rule: the presence of primitive defenses does not rule out a neurotic-level organization, but the absence of mature ones does (2011, p. 56). The defenses section describes each of these.

Reality testing

The ability to appreciate conventional notions of what is realistic. Kernberg proposed that the adequacy of reality testing, rather than “insight into illness,” is what separates borderline from psychotic organization. One way to assess it is to point out something unusual in how a person presents and ask whether they can see why others might find it odd (McWilliams, 2011, p. 65).

Clinicians also attend to how far a person can observe their own difficulties: whether troubling patterns feel foreign and puzzling to them (“ego alien”) or simply like the way things are (“ego syntonic”) (McWilliams, 2011, p. 57). And they attend to their own emotional reactions. McWilliams describes the clinician’s typical feelings as broadly benign with neurotic-level clients, intense and often split between rescue and punishment with borderline-level clients, and strongly protective with psychotic-level clients (2011, pp. 58, 62, 67).

The PDM-3 recommends that level be assessed after considering the 13 mental capacities of its M axis, and it describes the levels as a general synthesis of those capacities (McWilliams & Shedler, 2026, p. 656). Each capacity is rated from 1 to 5, and the total (13 to 65) maps roughly onto the levels: healthy functioning corresponds to the top band (M1), neurotic to M2 and M3, borderline to M4 through M6, and psychotic to M7 (Lingiardi, Muzi, & Bornstein, 2026, pp. 738–740). The capacity profile adds detail the level alone cannot: two people organized at a borderline level may get there by quite different routes, one mainly through cognitive schemas and frequent immature defenses, the other through impaired relationships, poor self-integration, and midlevel defenses (p. 710).

The Levels

Healthy

Most mental capacities are well developed and reliably present. People have characteristic styles but often blend several, and they have enough flexibility to adapt to hard realities, though not necessarily to severe trauma (McWilliams & Shedler, 2026, p. 657).

Neurotic

Identity, reality testing, and relationships are basically sound, but certain stresses meet a comparatively narrow, rigid range of responses. Difficulties tend to be confined to particular areas and are often felt as inner conflict (McWilliams & Shedler, 2026, p. 657).

Borderline

Identity is poorly integrated, primitive defenses predominate, and reality testing is fragile but basically intact. Emotions and relationships are often turbulent, though some people at this level are quiet and withdrawn. As a general rule, people whose personality difficulties are severe enough for a DSM personality disorder diagnosis function at this level (McWilliams & Shedler, 2026, pp. 655–656, 658).

Psychotic

Identity diffusion, poor differentiation between self and others, difficulty telling fantasy from reality, primitive defenses, and marked deficits in reality testing, sometimes in people who have never had a diagnosed psychotic illness (McWilliams & Shedler, 2026, pp. 660–661).

Higher and Lower Borderline

The borderline region is wide. McWilliams, following the research of Roy Grinker and colleagues, describes a range of severity “from the border with the neuroses to the border with the psychoses,” borders she calls somewhat arbitrary to begin with (2011, p. 83). The PDM-3 accordingly divides borderline organization into higher levels, closer to neurotic organization, and lower levels, describing more severe disturbance (McWilliams & Shedler, 2026, p. 658).

Several systems build this split in. The PDC-3 asks raters to use a score of 6 for people who move between the borderline and neurotic levels and a score of 3 for those who move between the borderline and psychotic levels (Gordon & Bornstein, 2025). Kernberg’s group’s Structured Interview of Personality Organization (STIPO) distinguishes three borderline levels (Hörz-Sagstetter, Ohse, & Kampe, 2021), and the M axis spreads borderline functioning across three bands, from moderate impairments to significant defects (Lingiardi et al., 2026, p. 738).

The distinction matters in practice. McWilliams writes that the closer a person is to neurotic functioning, the better they respond to more “uncovering” treatment, while people who border on psychosis do better with a more supportive style (2011, p. 83). The PDM-3 reports the same clinical consensus: more exploratory, insight-oriented treatment for higher-level borderline patients and more supportive, capacity-building treatment for lower-level ones (p. 658). Research reviewed by Hörz-Sagstetter and colleagues (2021) found that patients at lower borderline and psychotic levels were more likely to drop out of treatment, and that long-term therapy showed better long-term results for people with lower levels of organization. The borderline page explores the difference in detail.

Other Systems Compared

The psychodynamic levels are one of several current ways of rating how severe personality difficulties are. Reviewing three dimensional approaches (personality functioning, personality structure, and personality organization), Hörz-Sagstetter, Ohse, and Kampe (2021) cite a factor-analytic study suggesting that they share a strong common factor and several studies finding high convergence between them, while noting that each also captures unique aspects of personality pathology.

Kernberg’s structural interview and the STIPO

Kernberg’s structural interview is a clinical interview designed to bring out identity integration, defenses, and reality testing in the way a person talks about themselves and responds to the interviewer (Kernberg, 1981; McWilliams, 2011, p. 55). His colleagues turned it into the Structured Interview of Personality Organization, which rates identity, object relations, primitive defenses, coping and rigidity, aggression, and moral values (some versions also rated reality testing) and assigns one of six levels: normal, neurotic I and II, and borderline I, II, and III (Clarkin, Caligor, Stern, & Kernberg, 2004; Hörz-Sagstetter et al., 2021; Rufat et al., 2026; Stern et al., 2010). A revised, shorter version, the STIPO-R, has 55 items and yields five levels (normal, neurotic, and three borderline levels) (Blüml & Doering, 2021); it also includes a narcissism scale drawn from items across its domains (Rufat et al., 2026). In Kernberg’s framework, normal and neurotic organization are often grouped together, and the suspension of reality testing is the core feature of psychotic organization (Hörz-Sagstetter et al., 2021).

DSM-5-TR: Level of Personality Functioning Scale

The Alternative Model for Personality Disorders, kept in Section III of DSM-5-TR rather than adopted as the official system, rates personality functioning on the Level of Personality Functioning Scale. It covers identity, self-direction, empathy, and intimacy, each from 0 (no impairment) through 1 (some), 2 (moderate), 3 (severe), and 4 (extreme); moderate or greater impairment is the core requirement (Criterion A) for a personality disorder (Hörz-Sagstetter et al., 2021). Rufat and colleagues (2026) describe Criterion A as conceptually derived from Kernberg’s model but operationalized in a highly simplified form.

ICD-11: severity and “personality difficulty”

ICD-11 dropped the old list of personality disorder types in favor of a severity rating: personality difficulty, mild, moderate, or severe personality disorder, with optional trait qualifiers and an optional “borderline pattern” qualifier. Personality difficulty is explicitly not a mental disorder. It describes long-standing problems that show up only intermittently, for example under stress, or at low intensity, without compromising a person’s ability to keep a job, maintain friendships, and have reasonably satisfying intimate relationships (Bach & First, 2018).

The SWAP and its health index

The Shedler–Westen Assessment Procedure (SWAP) is completed by a clinician who sorts 200 descriptive statements by how well they fit a patient (Shedler & Westen, 2007). Besides scores for personality styles and disorders, it includes a Psychological Health Index, a global measure of strengths and resources on which scores above the average indicate greater psychological capacities (Garner et al., 2022). Most of the PDM-3’s diagnostic prototypes for personality styles were derived empirically from SWAP research; styles without an empirical prototype get clinically derived descriptions instead (McWilliams & Shedler, 2026, p. 666).

How they line up

A rough correspondence is possible, but it is a translation, not an equation. The PDM-3 says that as a general rule people with a DSM-level personality disorder function at a borderline level (p. 658), while Hörz-Sagstetter and colleagues (2021) note that some personality disorders can be found at the neurotic level and that the threshold for a severe personality disorder is borderline organization. Neither DSM-5-TR nor ICD-11 has a personality-level category corresponding to psychotic organization; psychotic states are classified elsewhere in those systems. The systems also measure somewhat different things. In one published case rated with both the LPFS and the SWAP, raters gave a high Psychological Health Index alongside LPFS ratings suggesting significant dysfunction, because the health index also counts resources such as assertiveness, energy, and pleasure in accomplishment (Garner et al., 2022).

Cautions

• Levels describe functioning, not people. McWilliams warns that viewing a person as organized at one level should not distract from their individuality and areas of strength (2011, p. 56), and that people are far more complex than even our most thoughtful categories (p. 19). Saying “a borderline” or “a psychotic” turns a description of functioning into an identity, and this site does not do it.
• Levels change. They shift under stress, across development, and over the course of good treatment. McWilliams describes a patient who began therapy prone to withdraw into a delusional paranoid state under mild stress and, over fifteen years, became a “bastion of resourcefulness” through serious family crises (McWilliams, 1999, p. 22). Studies of Kernberg’s model have found that personality organization improves over the course of treatment (Hörz-Sagstetter et al., 2021).
• Stress and situation can mimic structure. Under enough strain or trauma, the PDM-3 notes, any of us can look borderline or even psychotic; a man newly arrived in a country whose language he does not speak may appear paranoid or dependent for reasons that have nothing to do with his personality (McWilliams & Shedler, 2026, p. 654). Severe trauma can damage even people who were previously quite resilient (p. 657).
• Culture matters. Normality and pathology are not fixed and universal, and ignorance of cultural differences can lead clinicians to pathologize behavior that fits a person’s own cultural norms (McWilliams & Shedler, 2026, pp. 654, 661–662). Postmodern critics have pointed out that models of “normal development” carry implicit cultural prescriptions (McWilliams, 2011, p. 44). One of the PDM-3’s own published case illustrations warns explicitly that a traditional reading could easily have pathologized a client’s nonbinary identity, a mistake normative theories have made before with women, Black people, Indigenous people, and lesbian and gay people (Lingiardi & McWilliams, 2026b, p. 55).
• Earlier is not simply sicker. The old assumption that the earlier a developmental obstacle, the more disturbed the person, is in McWilliams’s words “a great oversimplification” (2011, p. 43). The PDM-3 notes that viewing level as fixation at a developmental stage “now holds little currency”; contemporary theorists see severity as a confluence of genetic heritability, temperament, early experiences, and attachment, among other factors (p. 656).
• Level is not prognosis on its own. One of the PDM-3 case illustrations describes a man rated at a (low) neurotic level whose mental capacities were nonetheless rated as having major impairments, showing that level and capacity profile can diverge (Lingiardi & McWilliams, 2026b, p. 32). And a woman whom McWilliams first met after years of being diagnosed with schizophrenia went on, through long therapy, to a life in which a colleague described her as “eccentric and lovable” (McWilliams, 2004, pp. 221, 238).
• Reading is not diagnosis. These descriptions are for understanding, not for rating yourself or anyone you know. The PDM-3 itself calls its treatment recommendations general guidance with many exceptions, “not ‘rules’” (p. 661).

History

Before modern psychiatry, observers mostly sorted people into sane and insane (McWilliams, 2011, p. 45). Emil Kraepelin’s careful classification of syndromes kept a broad divide between conditions in which people stay in touch with reality and those in which they do not (p. 46). Freud worked within that divide. As McWilliams summarizes, a woman with a neurosis knew at some level that the problem was in her own head, while a woman in a psychotic state believed the world was out of kilter; after Freud’s structural model, neurotic people were seen as having defenses that were too rigid and psychotic people as having defenses that were too weak (pp. 46–47). In his 1924 papers Freud framed neurosis as a conflict between the ego and the id, and psychosis as a disturbance between the ego and the external world (Freud, 1924/1961; de Oliveira Moreira & Drawin, 2015).

Within the neurotic category, Wilhelm Reich (1933/1972) distinguished symptom neuroses from character neuroses, a distinction that, McWilliams notes, lives on in the DSM’s separation of “disorders” from “personality disorders” (2011, p. 47).

The middle ground came next. Clinicians described patients who were, in McWilliams’s phrase, “too sane to be considered crazy, and too crazy to be considered sane” (2011, p. 52). Adolph Stern (1938) used “borderline” for patients who got worse in standard analysis; Helene Deutsch (1942) described the “as-if” personality; Hoch and Polatin (1949) proposed “pseudoneurotic schizophrenia”; Melitta Schmideberg (1947) described the “stable instability” of these patients; Robert Knight (1953) wrote on “borderline states”; and Grinker, Werble, and Drye (1968) documented a borderline syndrome spanning a range of severity (McWilliams, 2011, pp. 34, 52; McWilliams & Shedler, 2026, p. 655). Otto Kernberg’s 1967 paper “Borderline Personality Organization” and his 1975 book gave the concept its structural form: identity diffusion, predominantly primitive defenses, and fragile but intact reality testing (Kernberg, 1967, 1975; McWilliams & Shedler, 2026, p. 655).

In 1980, DSM-III adopted “borderline” as the name of a specific personality disorder. McWilliams argues that this legitimized a valuable concept at the price of losing its original meaning as a level of functioning, since the DSM definition drew on research with what most analysts would have seen as a histrionic style at the borderline level; Kernberg began distinguishing borderline personality organization from borderline personality disorder (2011, pp. 52–53).

Heinz Kohut offered a different picture. Where Kernberg saw serious narcissistic pathology structurally, as a self that had developed in a deviant direction, Kohut saw it developmentally, as normal growth that had been stunted (McWilliams, 2011, pp. 188–189). Self psychology frames severity in terms of the cohesion or fragmentation of the self; Lawrence Hedges, as McWilliams summarizes him, recommended listening for self-psychological themes of self-cohesion and fragmentation with narcissistically organized clients and for object-relational themes of merger versus abandonment with borderline ones (McWilliams, 2004, p. 138). Kernberg in turn suggested that Kohut’s approach amounted to supportive therapy suited to more disturbed narcissistic patients, even though Kohut worked mostly with high-functioning ones (McWilliams, 2011, p. 189). Self psychology also widened what clinicians assess at every level, adding the question of how vulnerable a person’s self-esteem is and what they do when it is threatened (pp. 37–38).

McWilliams’s Psychoanalytic Diagnosis (1994; 2nd ed., 2011) brought the level-by-style grid to a generation of clinicians, and she preserved the original meaning of “borderline” in the personality section of the first Psychodynamic Diagnostic Manual (PDM Task Force, 2006; McWilliams, 2011, p. 53). PDM-2 (Lingiardi & McWilliams, 2017) introduced a psychotic level of personality organization (Lingiardi, McWilliams, & Muzi, 2017) and adopted Kernberg’s solution of describing both a borderline level and a borderline personality style. Readers found the double meaning confusing, so PDM-3 (2026) keeps “borderline” only for the level and renames the style “emotionally dysregulated personality” (McWilliams & Shedler, 2026, pp. 656, 696). PDM-2 had expanded the M axis from 9 to 12 capacities (Lingiardi, McWilliams, & Muzi, 2017), and PDM-3 expanded it to 13 (Lingiardi & McWilliams, 2026a, p. 12). Meanwhile the empirical turn, from the SWAP to the STIPO, the LPFS, and ICD-11, has made severity of personality functioning a central idea well beyond psychoanalysis (Hörz-Sagstetter et al., 2021).

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