Levels Over Labels

A psychoanalytic overview of the neurotic personality organization

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Levels of Personality Organization – Neurotic Level

This is the first of a three-part series on analytic approaches to personality organization and how we can use this framework to develop a psychoanalytic formulation of our patients. It contrasts with how the DSM is currently organized, and apparently how it will be organized in future editions. I personally find the use of levels of personality organization incredibly useful in conceptualizing complicated clinical presentations, and I’ll be referring back to this series frequently in other writings.

The DSM categorizes symptom clusters into syndromes which it then mislabels “diagnoses.” These symptom clusters are thought to aggregate in ways that provide useful pathophysiological or prognostic information. See here for one of my critiques of this approach.

Many analysts, by contrast, categorize people and their symptomatic presentations along two separate axes: 1) the level of personality organization and 2) their characterological traits. Nancy McWilliams, in her book Psychoanalytic Diagnosis (1), does a wonderful job reviewing this approach to case construction. The seminal works on personality organization come from Otto Kernberg (2, 3), which I highly recommend. In this piece I focus primarily on levels of personality organization, using the characterological trait of obsessionality as a clinical illustration across levels.

The three levels of personality organization in patient populations are neurotic, borderline, and psychotic. Kernberg also describes a fourth, “healthy” level of organization (4), which I will not be addressing in this series.

Each level exists as a spectrum, so people can be organized at the juncture points — low neurotic/high borderline, for example, or low borderline/high psychotic. Because these categories are not truly categorical, the defining features of each bleed into the others at the extremes, which can generate significant diagnostic confusion.

These levels of organization intersect with characterological traits, such that a person can have an obsessional character organized at a neurotic, borderline, or psychotic level. Similar intersections exist across many analytic character descriptions — schizoid, histrionic, narcissistic, and others.

Neurotic Level of Organization

People organized at a neurotic level tend to struggle with the issues Freud described in his account of the Oedipal phase (5, 6). In relationships, they characteristically experience jealousy and competition reminiscent of the oedipal struggle — the wish to claim the opposite-sex parent as a love object and defeat the rivalrous same-sex parent. Every parent who has heard their child announce plans to marry them one day is witnessing the oedipal phase in action. These triangular dynamics, involving the individual, their love interest, and a rival, form a triangle with a person at each point, all in constant relational engagement.

This triangular struggle can surface in contexts that seem, at first pass, unrelated to relationships, but issues around fear of success (sabotaging professional or academic advancement) and writer’s block are also examples of oedipal conflicts; a fear of upstaging or surpassing the same-sex parent and inciting their wrath.

Those organized at a neurotic level tend to become especially angry around competition, jealousy, and justice. They may be overtly competitive, or the opposite — outwardly meek while unconsciously struggling with unexpressed competitive feelings. Regardless, themes of rivalry and injustice reliably fire them up, a further consequence of the basic triangular approach they take to relationships and relationship-analogous conflicts.

Just as triangular issues around competition incite their anger, their primary fear is also driven by competitive dynamics. They fear punishment (the Freudian castration fear as a quintessential example). They dread retribution from the same-sex parent for their sexual fantasies toward the opposite-sex parent, or for aggressive fantasies toward the same-sex parental rival. While the unconscious targets of these feelings are the parents themselves, the more conscious manifestations are typically directed toward parental stand-ins: a romantic partner, a boss, a mentor. These fears generate intense guilt, which Freud attributed to the harsh internal condemnation of an overactive superego. Individuals at the neurotic level are accordingly prone to guilt, sometimes cripplingly so. Their deepest wish, then, is to compete freely, both romantically and professionally, without punishment and without guilt.

General Case Example

Someone organized at a neurotic level with an obsessional character might be perfectionistic, detail-oriented, rigid, and judgmental. His careful and precise nature may make him exceptionally effective in certain kinds of work. But he may feel held back by a tendency towards procrastination and rumination, and his boss might complain that he can’t see the forest for the trees. He might feel a particular discomfort around hygiene and sexuality, which can at times feel disgusting or dirty. He is likely preoccupied with rivalry in romantic contexts, overtly jealous, or alternatively ruminating on feelings of inadequacy relative to men he imagines as competitors for his partner’s attention.

At times, his obsessional character may balloon into full-blown obsessive-compulsive disorder. When this happens, he experiences the obsessions and compulsions as ego-dystonic — foreign to his sense of self — and something he desperately wants to be rid of. In dynamic or analytic therapy, he will characteristically rely on intellectualization, isolation of affect, and reaction formation as his primary defenses, which will require slow and careful defense interpretation to loosen his rigidity, deepen his experience of emotional richness, and help him find greater comfort with his own competitive and aggressive feelings.

Below is a table organizing each of the three levels of personality organization by their defining features. This table will be included in each of the three posts in this series.

References

1. McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. 2nd ed. New York: Guilford Press; 2011.

2. Kernberg OF. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson; 1975.

3. Kernberg OF. Severe Personality Disorders: Psychotherapeutic Strategies. New Haven: Yale University Press; 1984.

4. Kernberg OF, Caligor E. A psychoanalytic theory of personality disorders. In: Lenzenweger MF, Clarkin JF, eds. Major Theories of Personality Disorder. 2nd ed. New York: Guilford Press; 2005:114–156.

5. Freud S. The dissolution of the Oedipus complex (1924). In: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19. London: Hogarth Press; 1961:173–179.

6. Freud S. Three essays on the theory of sexuality (1905). In: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 7. London: Hogarth Press; 1953:123–246.