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Personality / Organization

Neurotic Level of Organization

In everyday speech “neurotic” is a mild insult. In psychodynamic diagnosis it means something close to the opposite. McWilliams calls it an irony that the term is now reserved by most analysts for people so emotionally healthy that they are considered rare and unusually gratifying clients; it has come to denote “a high level of capacity to function despite emotional suffering” (McWilliams, 2011, p. 56). In Freud’s day the word covered almost everyone who was not schizophrenic, organically ill, psychopathic, or manic-depressive. As clinicians learned how deep some problems run, the category narrowed (p. 56).

People organized at the neurotic level have a basically solid sense of who they are, good reality testing, and mostly good relationships. What sets them apart from the healthy level is relative rigidity: they respond to certain stresses with a comparatively narrow range of responses, defenses, and coping strategies (McWilliams & Shedler, 2026, p. 657). Their difficulties tend to stay in particular areas of life, and they often experience them as inner conflict: wanting something and forbidding it at the same time, or feeling angry while believing the anger is unjustified (p. 657).

Many people who see a therapist, and many who never do, live here. Being organized at the neurotic level is compatible with real pain, including depression, anxiety, and symptoms that limit a life. It describes how the suffering is organized, not how much there is.

Hallmarks

Identity
Somewhat integrated, in McWilliams’s phrase, with a sense of continuity over time. Asked to describe themselves, people at this level can delineate their temperament, values, tastes, habits, convictions, virtues, and shortcomings, and they describe important others in multifaceted, recognizably human ways (McWilliams, 2011, p. 57).
Reality testing
Solid. Apart from the effects of drugs, illness, or posttraumatic flashbacks, people at this level are strangers to hallucinations and delusions, and the therapist does not feel pressured to see the world through a distorting lens (McWilliams, 2011, p. 57).
Defenses
People at this level rely mainly on mature defenses, using primitive ones mostly under unusual stress. McWilliams’s rule of thumb: the presence of primitive defenses does not rule out neurotic-level organization, but the absence of mature ones does (2011, p. 56). The traditional literature saw repression as their basic defense (p. 56). The PDC-3 associates this level with repression, reaction formation, intellectualization, displacement, and undoing (Gordon & Bornstein, 2025). The rigid defenses tend to concern one area, such as authority, rather than every relationship (McWilliams & Shedler, 2026, p. 657).
Object relations
Outside their areas of difficulty, people at this level may have a satisfactory work history, good relations with others, a satisfying sexual life, and the ability to tolerate painful feelings without acting impulsively (McWilliams & Shedler, 2026, pp. 657–658). In McWilliams’s developmental language, they have more or less successfully traversed Erikson’s stages of basic trust and autonomy and made progress toward identity and initiative (2011, p. 58). Their conflicts tend to be triadic, involving love, rivalry, and guilt among three people rather than a struggle over closeness and separateness between two (p. 68).
Self-observation
Neurotic-level people often have some perspective on their recurring difficulties and can imagine how they would like to change (McWilliams & Shedler, 2026, p. 658). Early in therapy they show what Richard Sterba called the “therapeutic split” between an observing and an experiencing part of the self (McWilliams, 2011, p. 57). Much of what troubles them feels foreign and odd to them, or can become so; this is the capacity the M axis calls exploring one’s inner life.
Other capacities
The PDC-3 summarizes the level as a basically good sense of identity, good reality testing, mostly good intimacies, fair resiliency, and fair affect tolerance and regulation, with rigidity and a limited range of defenses (Gordon & Bornstein, 2025). On the M axis, neurotic functioning corresponds to M2 (good functioning with some specific areas of difficulty) and M3 (mild constrictions and inflexibility in areas such as self-esteem regulation, impulse regulation, and defensive functioning) (Lingiardi, Muzi, & Bornstein, 2026, pp. 738–739).

How It Feels From the Inside

McWilliams describes neurotic-level people as seeking help not because of problems in basic security or agency, but because they keep running into conflicts between what they want and obstacles they suspect are of their own making (2011, p. 58). The characteristic anxiety is not that the self will dissolve or be abandoned, but fear of punishment for forbidden sexual, aggressive, or dependent wishes, with no threat to one’s sense of reality or identity (McWilliams, 1999, p. 79). The suffering, she writes elsewhere, seems well demarcated into a particular area, and the person comes across as a separate person with a strong sense of “I” (1999, p. 77).

This shows in how people relate to their own symptoms. A neurotically organized man with paranoid tendencies is willing to consider that his suspicions come from an inner disposition to see hostility in others. A neurotic-level person with compulsive rituals may say they are crazy but that skipping them brings anxiety; a woman with a cleaning compulsion is embarrassed to admit how often she washes the sheets (McWilliams, 2011, pp. 57–58). The pattern feels like a problem to them, not simply like the way the world is.

That stance has a cost and a gift. The cost is self-consciousness, guilt, and the frustration of repeating a pattern one can see. The gift is that the person and the therapist can stand together looking at it.

Across the Styles

The PDM-3 names the depressive, obsessive–compulsive, phobic (see anxious–avoidant), and hysteric styles as common at this level, each with its own domain of difficulty: loss, rejection, and self-punishment in depressive personalities; gender, sexuality, and power in hysteric personalities; authority and control in obsessive–compulsive ones (McWilliams & Shedler, 2026, p. 657). The word “hysteric” has historically been used for this style at higher levels and “histrionic” at borderline and psychotic levels (pp. 657, 686).

Other styles appear here too. Dependent people at the neurotic level may first seek treatment in midlife or later, after a bereavement, divorce, or retirement removes clearly defined roles (p. 673). Anxious personalities are easily recognized from the neurotic through the borderline ranges (p. 676). People with a narcissistic style toward the healthier, neurotic end may be socially appropriate, successful, and charming, if somewhat limited in intimacy (p. 688). McWilliams’s example of a neurotically organized paranoid man shows that even styles that load toward lower levels can be found here (2011, p. 57). The PDM-3 distinguishes a higher-functioning, more conflict-based version of the schizoid style from lower-level, more deficit-based versions (McWilliams & Shedler, 2026, p. 683).

Because flexibility increases with health, people at this level usually show blends of styles rather than one pure type (McWilliams & Shedler, 2026, p. 665). McWilliams’s patient Molly, described below, had obsessive–compulsive, hysterical, counterdependent, depressive, and masochistic features at once (2004, p. 201).

In Therapy

Neurotic-level people usually form a working alliance quickly. In plain terms, they and the therapist feel like partners on the same side, facing a problematic part of the person together. McWilliams quotes the sociologist Edgar Friedenberg’s image of two young men tinkering with a car, one expert and one interested learner, and says that such clients evoke in the therapist “neither the wish to kill nor the compulsion to save” (2011, p. 58). Countertransference, the therapist’s own emotional response, tends to be comfortable and more interesting than disruptive; transference, the person’s tendency to experience the therapist through the lens of past relationships, can usually be recognized as such, so pointing out a resemblance to a parent sparks interest more than shame (McWilliams & Shedler, 2026, p. 662).

This is the group for which classical psychoanalysis and exploratory (“uncovering”) psychodynamic therapy were designed, and for whom they work best (McWilliams, 2011, pp. 72–73). The aims can be ambitious: removing unconscious obstacles to love, work, and play, and pursuing difficult truths about oneself, which requires what Theodor Reik called moral courage (p. 72). Short-term dynamic therapies, group therapy, and non-psychodynamic approaches also tend to help; McWilliams notes that in cognitive-behavioral therapy such clients tend to do the homework (pp. 73–74). The PDM-3 adds that regressive feelings tend to stay within the session, and that exploring the historical roots of current feelings usually deepens engagement (p. 662).

Technique follows from these capacities. With neurotic-level clients, McWilliams writes, a therapist can speak bluntly and sparingly, naming the side of a conflict the person is not aware of, and the client feels understood, “even if slightly wounded” (2011, p. 87). Linking a reaction to the therapist with a figure from the past can be productive (p. 88), and interpretations often land best when the person is emotionally aroused (p. 92). McWilliams notes that therapy with neurotic-level people tends to become most difficult in its middle phase, when transferences begin to emerge with primitive intensity, whereas with more disturbed people the hardest part comes first (2004, p. 198).

The traditional distinction between a symptom neurosis and a neurotic character still matters. When a pattern is woven into personality, the therapist’s first task may be to help the person see as a problem what has always felt normal, “making ego alien what has been ego syntonic,” and the alliance may take time to build (McWilliams, 2011, pp. 48–50).

How Different Thinkers See It

Freud

For Freud, neurosis meant a conflict between the ego and the id, in contrast to psychosis, a disturbance in the ego’s relation to the outside world (Freud, 1924/1961; de Oliveira Moreira & Drawin, 2015). As McWilliams summarizes the structural view, neurotic people suffer because their defenses are too automatic and inflexible, cutting them off from energies that could be used creatively. She compares the neurotic mind to a pot with the lid on too tight, so that therapy’s job is to let some steam escape (2011, pp. 46–47).

Reich and the ego psychologists

Wilhelm Reich (1933/1972) distinguished symptom neuroses from character neuroses, and Herman Nunberg offered questions to tell them apart: Is there a clear precipitant? Did anxiety rise dramatically? Did the person come on their own? Do the symptoms feel foreign? Can the person ally with the therapist against the problem? (McWilliams, 2011, pp. 47–48). Ego psychologists located health in the flexible use of mature defenses (p. 29), and the PDM-3 draws on David Shapiro’s work in defining this level by relative rigidity (McWilliams & Shedler, 2026, p. 657).

Erikson

Erik Erikson’s stages framed neurotic-level difficulty as trouble at the stage of initiative versus guilt, with basic trust and autonomy largely secured (McWilliams, 2011, pp. 53, 58).

Kernberg

Kernberg defines neurotic organization by an integrated identity, mostly mature defenses, and stable reality testing, often grouping it with normal functioning (Hörz-Sagstetter, Ohse, & Kampe, 2021). His group’s STIPO interview divides it into two levels, neurotic I and II (Hörz-Sagstetter et al., 2021). In Kernberg’s scheme, as in the PDM, some personality disorders can occur at this level, though severe ones do not (Hörz-Sagstetter et al., 2021).

Kohut and the relational tradition

Self psychology widened what clinicians look for even in people who are not notably narcissistic: how vulnerable their self-esteem is, and what they do when it is threatened (McWilliams, 2011, pp. 37–38). Lawrence Hedges, whose scheme McWilliams summarizes, recommended listening for classical Freudian themes of drive, structural conflict, and defense with neurotic-level clients, and for self-psychological, object-relational, and Kleinian themes with progressively more disturbed ones (McWilliams, 2004, p. 138).

Where they disagree

Older literature defined this level by the use of repression. The PDM-3 emphasizes rigidity and the availability of mature defenses under stress, and suggests that what separates borderline from neurotic organization may be less the presence of costly defenses than the relative absence of mature ones when stressed (McWilliams & Shedler, 2026, p. 658). Developmental theorists once tied the neurotic level to the oedipal phase; the PDM-3 says that viewing levels as fixation at developmental stages “now holds little currency” (p. 656).

In Other Systems

The correspondences below are approximate and are this site’s mapping.

The systems can diverge in a single case. One of the PDM-3’s case illustrations rates a man’s personality organization as neurotic (low) while rating his mental capacities as showing major impairments (Lingiardi & McWilliams, 2026, p. 32), a reminder that level of organization and the profile of mental capacities are separate questions.

Examples

Molly

McWilliams presents Molly as a contrast case to her borderline-level patients: a woman with impressive ego strength, a capacity for alliance, and strong motivation, whose disabling difficulties were woven into personality but whose character structure was in the neurotic range. At 27 she was highly intelligent, controlled, depressed, and anxious, chronically put others’ needs before her own, and could rarely identify her feelings. McWilliams treated her with a traditional psychoanalytic approach, and Molly, as McWilliams puts it, eventually made herself well.

Nancy McWilliams, Psychoanalytic Psychotherapy (2004), pp. 197–201, 216–218

The man who scheduled serenity

A 30-year-old accountant, raised to fulfill his family’s hopes, came to McWilliams wanting “more balance” and returned with a detailed daily program allotting time to exercise, play with his children, hobbies, and even lovemaking. Her first task was to suggest that the solution was part of the problem: he was pursuing serenity as another job to do. He grasped the idea intellectually but had no felt memory of a less driven way of living, an example of a pattern so woven into character that it first has to be seen as a pattern.

Nancy McWilliams, Psychoanalytic Diagnosis (2nd ed., 2011), p. 49

Grace

In one of the PDM-3’s online case illustrations, Grace, a 48-year-old saleswoman, came to therapy devastated after a boyfriend ended their relationship without explanation. Over six months of short-term psychodynamic work she grieved, questioned her idealization of him, and recognized her anger. She overcame her depression, regained a sense of agency, and began choosing partners rather than waiting to be chosen. The authors rate her at the neurotic level with a depressive style, and note that without attention to social context, including how others responded to her conventional beauty, she might have been misread as having a histrionic personality disorder.

Lingiardi & McWilliams (Eds.), PDM-3 Online Supplement (2026), pp. 47–49

How It Differs From Look-Alikes

The healthy level
Both share solid identity and reality testing. The neurotic level is marked by rigidity in particular areas: a narrower range of responses to certain stresses (McWilliams & Shedler, 2026, p. 657). The PDC-3 treats the line as a gradient (Gordon & Bornstein, 2025). See the healthy level.
Higher-level borderline organization
Neurotic-level people can usually see a transference as a transference and take an interpretation as information rather than attack (McWilliams & Shedler, 2026, p. 662; McWilliams, 2011, pp. 87–88). At the borderline level, the PDM-3 suggests, the key difference may be the relative absence of mature defenses under stress (p. 658). See the borderline level.
A neurotic symptom
A symptom such as a phobia or an obsession can occur at any level, and McWilliams notes that some neurotic reactions are more crippling than some personality disorders (2011, p. 51). The level describes the personality in which a symptom appears, not the symptom itself (p. 54).
“Neurotic” as an insult
In casual speech the word suggests someone fussy, anxious, or difficult. In this framework it means close to the opposite: a high capacity to function despite emotional suffering (McWilliams, 2011, p. 56).

History

In late nineteenth-century psychiatry, “neurosis” covered a wide range of problems, minor and major, in which the capacity to perceive reality is intact (McWilliams & Shedler, 2026, p. 655). Freud used Kraepelin’s categories and thought in terms of the neurosis–psychosis divide; only late in his career did he begin to distinguish an obsessional neurosis in an otherwise non-obsessive person from obsession that was part of an obsessive–compulsive character (McWilliams, 2011, p. 46).

Wilhelm Reich’s distinction (1933/1972) between symptom neuroses and character neuroses, and Nunberg’s questions for telling them apart, made personality itself a focus of treatment (McWilliams, 2011, pp. 47–48). For decades, McWilliams writes, the categories of symptom neurosis, character neurosis, and psychosis were the main way of thinking about severity, which implied wrongly that all character problems are worse than all neuroses (p. 51). Otto Fenichel’s chapter on “character disorders” in The Psychoanalytic Theory of Neurosis (1945) remains, in her view, the classic statement of the symptom–character distinction (p. 68).

As the borderline concept took shape in the mid-twentieth century, many patients once called neurotic were reclassified, and the neurotic level came to mean the healthier part of the spectrum (McWilliams, 2011, p. 56). Kernberg’s structural model defined neurotic organization by integrated identity, mature defenses, and intact reality testing (Hörz-Sagstetter et al., 2021). The PDM separated a healthy level from the neurotic one and, in PDM-3, defined the neurotic level by relative rigidity within an otherwise well-developed set of capacities (McWilliams & Shedler, 2026, p. 657).

Sources