Understanding psychoanalytic diagnosis: a different way of seeing people

Most people walk into a therapist’s office with a question, even if they don’t say it out loud: What’s wrong with me?

Relationships keep falling apart in the same way. Anxiety won’t let up and it’s loud and exhausting. Everything feels dull and muted. Our mental health system offers an answer with a diagnosis. Receiving a diagnosis, though it can be daunting at times, can provide tremendous relief and validation by finally providing a name and a reason for people’s experiences. Sometimes, that relief can be accompanied by a desire for deeper understanding. Okay, I know what’s wrong with me, but I still don’t REALLY know what’s going on with me.

This is where psychoanalytic diagnosis comes in. Instead of asking what symptoms do you have?, it asks something closer to who are you? and how did you come to be this way? It fills in the details to the broad strokes that a general diagnosis provides.

DSM vs PDM

The DSM (the Diagnostic and Statistical Manual of Mental Disorders, currently in its 5th edition text revision) is the gold standard for mental health diagnoses in the US. It uses a categorical model. You either meet criteria for a diagnosis or you don’t. It was designed to describe what clinicians observe without taking a position on why. So it makes sense why it is commonly used in clinical and research settings.

Psychoanalytic diagnosis utilizes the PDM (Psychodynamic Diagnostic Manual, currently in its 3rd edition), which, on the other hand, is dimensional. People and their symptoms are seen as falling onto a spectrum as it relates to their function, which is also dynamic and influenced by different factors. For example, rather than simply determining whether someone “has” borderline personality disorder based on a checklist of symptoms, it seeks to determine where someone falls on the continuum of borderline functioning, from higher to lower levels of functioning.

The dimensional approach understands that people are complex and, therefore, do not fall into neat boxes. Two people can meet every criterion for major depressive disorder, but their experiences of depression as well as their coping mechanisms can be drastically different. One might be someone who represses their anger and has built a life around self-sacrifice. The other might lack a solid sense of self, leaving them feeling empty, and work overtime to present themselves as perfect to avoid rejection or abandonment. This would mean that the treatment implications for the two would be different.

Psychoanalytic diagnosis is the framework that makes those distinctions visible. This is what makes it especially helpful for clinicians in therapy. The clinician would understand the approach that would work best for each person, and have a sophisticated understanding of why.

What does psychoanalytic diagnosis entail?

Psychoanalytic diagnosis comes from a long tradition of psychoanalytic thought, and its most accessible modern articulation is probably Nancy McWilliams’ book Psychoanalytic Diagnosis, now in its second edition, along with the Psychodynamic Diagnostic Manual (the PDM-3, published in January 2026), which she co-edited with Vittorio Lingiardi.

Before we go into the meat and potatoes, I want to make a preface for folks who are new to psychoanalytic diagnosis and/or are not familiar with psychoanalytic jargon. First, I find it helpful to view psychoanalytic diagnosis less as a diagnostic tool, but as a descriptive framework. Think of it similar to the Myers-Briggs or the Enneagram in that they provide understanding of different personality styles and common characteristics within those styles.

Because this framework shares some terminology with the DSM, you may encounter labels that initially feel pathologizing or insulting. It is important to remember that these terms are used here to describe internal patterns and defenses, not to diagnose or judge. I suggest approaching this introduction with a “clean slate,” setting aside prior associations with clinical diagnostic labels to better understand and appreciate what these categorizations capture.

Now back to our regular programming.

The two dimensions of psychoanalytic diagnosis: how you’re organized and what you’re organized around

Psychoanalytic diagnosis is made up of two axes that can work together to create a rich picture of someone’s functioning and personality.

The first is level of personality organization, essentially, how you hold yourself together when things get difficult. McWilliams describes three broad levels of organization: neurotic, borderline, and psychotic. They describe something more like the structural integrity of a person’s identity, their capacity to test reality, and the kinds of psychological defenses they rely on. In other words, they tell you how you hold yourself together, how you stay grounded in reality, and your “go-to” coping and defense mechanisms to protect yourself when you’re hurt or stressed.

Someone organized at a neurotic level has a stable sense of who they are, can see other people as complex and whole, and tends to use more flexible defenses, like finding logical reasons for their feelings (rationalization) or briefly pushing uncomfortable thoughts out of awareness (repression).

Someone at a borderline level may find it hard to see people as complex, sometimes swinging between seeing them as “all good” or “all bad.” Their defenses are often more reactive, like keeping conflicting feelings strictly separated (splitting) or unknowingly attributing their own difficult emotions to others (projection).

Someone at a psychotic level has a much harder time maintaining a consistent grip on reality, meaning they may struggle to maintain a shared sense of reality with those around them.

In essence, the different levels can be seen as different levels of functioning as it pertains to sense of self, boundaries, emotion regulation, and insight. It’s important to note that these levels are not rigid categories, but on a spectrum. While we may be in one level at baseline, we can shift to different levels of organization during periods of stress or distress.

The second axis is character style, the particular flavor of a person’s personality organization. This is the part that may resemble the Myers-Briggs or the Enneagram, as referenced earlier. McWilliams identifies nine primary character styles: narcissistic, schizoid, depressive, masochistic, obsessive-compulsive, hysterical (or histrionic), paranoid, dissociative, and psychopathic. Each has characteristic defenses, interpersonal patterns, and developmental origins. Like Axis I, they exist on a spectrum from healthy to pathological.

What this looks like in practice

Let’s look at a fictional client, Marcus. He arrives at therapy describing himself as having imposter syndrome, despite being highly successful in his corporate career. He feels a constant, low-level anxiety that he isn’t doing enough and volunteers to take on extra work, which often leads to 80-hour work weeks and strained relationships at home. He has difficulty relaxing because he feels as though he is wasting time, and starts thinking about all the tasks he could be doing instead.

In therapy, he is very insightful and reflective. He is able to explain that his perfectionistic tendencies and feelings of inadequacy are rooted in trying to please his parents who had incredibly high expectations of him. He is also very compliant and takes notes of what was discussed in each session. He comes prepared with topics to discuss and brings his journal just in case he forgets an important detail. He readily implements any intervention the therapist suggests. When discussing difficult experiences he’s had in the past, his affect is incongruent as he is typically smiling and speaking with a brightness as if he is talking about a nice day he had. He longs for a relationship with someone reliable and competent so that he can have moments where he can truly “let go and be free from any sense of obligation.”

If we only used a DSM lens, Marcus might be categorized with Generalized Anxiety Disorder or, perhaps, traits of Obsessive-Compulsive Personality Disorder (OCPD). We might focus on cognitive-behavioral techniques to challenge his core beliefs of not being enough, replace negative thought patterns with balanced thoughts, and coping skills to help manage his anxiety and stress.

Through a psychoanalytic lens, however, we see a much richer picture. Marcus operates at a Neurotic level of personality organization. He has a stable sense of identity, tests reality well, and possesses the capacity for insight. However, his Obsessive-Compulsive character style dictates his internal world. He uses intellectualization to keep his feelings at a distance and reaction formation to manage his dependency needs by becoming the person on whom everyone else must rely.

His “efficiency” is actually a defense against the terror of being imperfect. By meticulously controlling his environment, he keeps his deeper fears of vulnerability at bay. Understanding this shifts the therapeutic goal: instead of just teaching him to delegate tasks, we explore the meaning of his control. What happens to his sense of self when he is not the one holding everything together? We move from managing symptoms to understanding his character, helping him transform rigid defenses into more flexible ways of living.

What to look for in a therapist who works this way

If this way of thinking resonates with you, here are some things to look for:

A psychodynamic or psychoanalytic therapist will typically be interested in your history, not just your current symptoms. They’ll ask about your family, your early relationships, and how you’ve tended to handle difficult feelings across your life. They’ll pay attention to what happens between the two of you in the room, to the patterns that emerge in the therapeutic relationship itself.

They’re less likely to assign homework or teach structured coping skills, though it’s commonplace for therapists to integrate interventions and skills from other modalities. They’re more likely to be curious about why you do what you do. Increased awareness of oneself is seen as an important driver to change.

Psychodynamic work tends to be long-term. It takes time to build rapport and understand the intricacies of a client’s history. It requires a certain level of safety and trust to address and work through defenses that have been built up throughout a client’s life to protect the most vulnerable parts of themselves. Furthermore, the defenses can often be unconscious, in that the client may not be aware that they are using certain defense mechanisms. When a therapeutic relationship has been built over a long period of time, there is a deeper level of attunement and understanding between the therapist and the client that cannot be rushed or manufactured.

At Coastal Therapy Group, our clinicians utilize a relational psychodynamic framework in some form. Even when the primary treatment modality is not explicitly psychodynamic, we utilize this framework to deepen our understanding of our patients. We use this approach not because it is the only valid one, but because we’ve found that it helps us see our patients more fully, which is often where the real work begins.

If that’s the kind of understanding you’re looking for, you can get started here.

This post is part of Undercurrent, CTG’s blog series on psychoanalytic diagnosis, personality structures, and how therapy works.