Personality runs on a continuum from neurotic (healthy or near healthy) through borderline to psychotic, and knowing the level matters more than knowing the dynamics. Every personality style can operate at any level, and the level changes how a patient relates to you and which therapies will work.
What it is
It is much more important to know what level a person is at than what their dynamics are.
“Kernberg in 1984 talked about how it's much more important to know what level the person is at than what their dynamics are”
21:10Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid PersonalityNov 2024Guest episode The familiar cluster A, B and C breakdown roughly maps onto the classical way of organizing personality pathology: psychotic, borderline and neurotic.
“everyone probably knows the classic breakdown of cluster A, cluster B, cluster C. But I think it's important to know that that roughly maps onto a classical way of organizing personality functioning psychopathology along psychotic borderline and neurotic”
23:44Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 The different personality disorders are different flavors, and each can operate in the neurotic, borderline or psychotic range.
“So all the different subtypes, all different personality disorders are different flavors, and they can all operate in the neurotic, borderline, or psychotic range”
27:53Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025
The three levels
Neurotic: full contact with reality, problems mostly about worry, fear and control, and a full, stable connection with other people and with themselves. In this framework neurotic just means healthy, or near healthy.
“someone who is neurotic has full contact with reality and doesn't really lose it okay their problems are mostly about worrying and fear and control And they are able to form a full and stable connection with other people and themselves psychologically”
24:06Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 Also said in 1 more episode
“But in this framework, neurotic just means healthy. Or near healthy, at least. It's a personality function that's as close to reality as how we define it”
25:43Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 Borderline: somewhere in the middle, with a medium-level ability to connect to themselves and others and to regulate emotions.
“the borderline range is people who are somewhere in the middle they've got characteristics Both, they're basically medium level in terms of their ability to connect to themselves, others, and regulate emotions”
24:45Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 Psychotic: thinking and reality testing are disrupted, especially under stress. In the original sense, it means a problem joining consensual reality, and you see it in many people who are not diagnosably schizophrenic but struggle to stay in reality or hold some really crazy ideas.
“Psychotic is when there is essentially psychosis in the way that we talk about loss of touch with reality. Okay. thinking process and reality testing is disrupted in some way that is different than normal people especially under stress”
24:26Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 Also said in 1 more episode
“if you use the term psychotic in the way that it was originally meant, namely... there's a problem with joining with consensual notions of reality. Then you see a number of people who aren't diagnosably schizophrenic but who are struggling to stay in reality or who have some really crazy ideas”
27:10Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid PersonalityNov 2024Guest episode
How we use it
The same dynamics look different by level. A neurotic-range obsessive-compulsive person has rituals they know are crazy, knows it involves internal anxiety they have to do something about, and can make a good relationship with a therapist.
“The neurotic range of obsessive-compulsive would be somebody who has ritualistic practices that they know are crazy. They know it involves internal anxiety that they have to do something about. They can make a good relationship with a therapist”
21:44Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid PersonalityNov 2024Guest episode Knowing the style shapes your stance even when you do not try to change it: a patient with schizoid psychology will do better if you give them a lot of space rather than move in on them.
“If the therapist appreciates that they have a schizoid psychology, you don't necessarily try to modify that, but it helps you to understand that that's the kind of patient that will do better if you give them a lot of space, rather than if you move in on them”
25:24Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid PersonalityNov 2024Guest episode CBT works but has limits, and it is not suitable for most people anywhere even slightly below the healthy neurotic range.
“it works you know and it may be limited in some places i think it's not suitable for most people who are anywhere even slightly below healthy neurotic range of personality functioning”
45:28Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 In healthier patients, erotic transference shows up gradually and in disguised forms. The patient is a little ashamed and embarrassed and can look at it with curiosity and self-reflection.
“the erotic transference presents gradually. Often, it Like it occurs in more disguised forms. The patient will be a little bit ashamed, embarrassed. They'll be able to look at it with more curiosity and more self-reflection”
29:21When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025
It also comes up on
- Alternative model for personality disordersWe prefer borderline personality organization and the alternative model, where we simply think in terms of impaired personality functioning.
- Borderline personality disorderBorderline began as a level of personality organization, not ill enough to be psychotic but more ill than neurotic. BPD as people talk about it is only one category within that organization, which also includes narcissistic, antisocial and histrionic types.
- Borderline personality disorderWe prefer Kernberg's borderline personality organization and the DSM-5 alternative model to the traditional criteria: think in terms of impaired personality functioning.
- Personality developmentPut simply, borderline personality organization is stunted, slowed or difficult interpersonal and emotional development: how we understand and feel about ourselves, our relationships and other people.
- SplittingIt is the fundamental defense of borderline personality organization, alongside identity diffusion, reliance on primitive defenses and, above all, difficulty integrating the positive and negative sides of relationships.
- Borderline personality organizationIt is not the same as borderline personality disorder. BPD as people talk about it is only one category within borderline personality organization, which also includes narcissistic, antisocial, histrionic and other types.
- Personality disordersOne stronger view: the only things we should consider personality disorders are those that fit under borderline personality organization.
From these episodes
- Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 · 7 points
- When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and LiabilityAug 2025 · 1 point
- Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid PersonalityNov 2024 · 4 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.