Psychodynamic diagnosis: understanding the person and their symptoms in context

Dr. Ali Al-Farhan
Consultant Psychologist and Psychotherapist - Associate Professor of Psychology

Two people may come to therapy using the same words: "I feel anxious all the time."

As we listen more closely, important differences emerge. One fears making a mistake that will cost them other people's respect; the other becomes anxious whenever someone they love seems to be pulling away. Some symptoms may overlap, while their triggers, meanings and the ways each person manages them differ.

This is where psychodynamic diagnosis becomes useful: understanding a person's suffering, how it fits into their particular experience, and what may help them change.

The examples on this page are fictional illustrations. They do not describe actual clients or provide diagnoses that can be applied to people who resemble them.

What is psychodynamic diagnosis?

Psychodynamic diagnosis is an assessment process concerned with symptoms and with how a person understands themselves and others, regulates feelings, and responds to need, conflict, loss and stress.

It explores possible connections between current difficulties, recurring relationship patterns, significant experiences, and wishes and fears that may not be clearly conscious. This understanding helps guide treatment and adapt it to the individual. American Psychoanalytic Association.

Distinguishing three levels helps clarify the approach:

Level	The question it helps answer
Diagnosis of a disorder	Do the symptoms meet criteria for a particular disorder? How severe and disruptive are they?
Psychodynamic assessment	How does this person function psychologically? What patterns, capacities and vulnerabilities are present?
Psychodynamic formulation	How do these findings fit together for this individual, and what do they mean for treatment?

A formulation brings the information together into a coherent individual understanding. It may include the circumstances in which a problem emerged, what helps maintain it, how the person protects themselves from emotional pain, and resources that can support treatment. Nancy McWilliams's work is an important reference for developing this individualized understanding. McWilliams, 1999.

How does it complement standard psychiatric diagnosis?

Psychodynamic assessment can be used alongside diagnostic classifications such as the DSM and ICD. A comprehensive clinical assessment needs to understand symptoms and their severity, as well as the person and their context.

The Psychodynamic Diagnostic Manual, Third Edition (PDM-3) organizes adult assessment around three main axes:

Personality, P: personality patterns and level of organization.
Mental functioning, M: capacities such as affect regulation, self-esteem, understanding mental states, and resilience.
Subjective experience of symptoms, S: how symptoms are experienced from within, including associated feelings, thoughts, bodily experiences and relationships.

The manual also considers strengths, developmental stage, and cultural, social and family factors. The diagnostic picture therefore includes capacities that treatment can build upon, alongside difficulties. Lingiardi & McWilliams, 2026.

What does the therapist try to understand?

Feelings and internal conflicts

A person may want two things that are difficult to reconcile: closeness and independence, expressing anger and preserving a relationship, or pursuing ambition and avoiding guilt toward others.

In psychodynamic thinking, this is an internal conflict. Such conflicts are part of psychological life. They become especially relevant to treatment when they are intense or repetitive and restrict a person's choices.

Assessment also distinguishes a conflict from a difficulty in a psychological capacity. One person may know they are angry but fear expressing it; another may struggle to identify or soothe the feeling in the first place. This difference can influence where treatment begins. Conflicts and psychological capacities are addressed in the Operationalized Psychodynamic Diagnosis (OPD) framework. Kessler et al., 2013.

Psychological defenses

Defenses are psychological processes that help us tolerate feelings, thoughts or situations that are difficult to manage. Many operate automatically, outside conscious attention.

Someone may turn to extensive explanation and analysis as a conversation approaches painful grief, or minimize the importance of a relationship after feeling let down.

Understanding these responses requires attention to their function and context. Logical thinking, for example, is a useful capacity; in a particular situation it may also distance a person from a feeling that is hard to bear.

Assessment considers a defense's flexibility, frequency and cost: does it support adaptation, or repeatedly prevent the person from understanding their feelings or seeking support? Contemporary literature examines defenses as a dimension that can be assessed and studied, while acknowledging methodological and cultural limitations. Lingiardi & Madeddu, 2025.

Sense of self and relationships

How does a person describe themselves? Does their sense of worth change dramatically with every criticism or disagreement? How do they see others when reassured, and when disappointed?

Other useful questions include whether they can maintain a balanced view of someone they love while angry with them, ask for help, set boundaries and tolerate differences.

Identity, the quality of relationships and defenses are central to Otto Kernberg and colleagues' model of personality organization, and to the STIPO-R, a semi-structured interview based on this model. Interview manual.

How does psychodynamic assessment proceed?

The process varies with the person's needs and the treatment setting. The following steps are an explanatory guide, rather than a standardized protocol that must be followed in this order for everyone.

1. Understanding why help is being sought now

The therapist begins with the person's concern: when did the difficulty begin, what makes it better or worse, and how does it affect work, sleep, relationships and everyday life?

They also explore why seeking help feels important at this particular time, and what the person hopes will change.

2. Building a comprehensive clinical picture

Assessment addresses mental health and treatment history, physical health, medication and substance use, functioning and safety as relevant.

Some symptoms may require medical assessment: changes in mood or concentration, for example, can be related to a medical condition. The need for psychotherapy, medication or their combination depends on the individual situation. National Institute of Mental Health.

3. Exploring history and influential experiences

The conversation moves toward important relationships, transitions, losses, successes and setbacks, and experiences that seem relevant to the problem.

This includes childhood when relevant, alongside adult experiences and current circumstances. McWilliams describes the value of gathering objective and subjective information in the initial interviews within a respectful relationship, allowing the person to say when a question feels difficult to address at present. McWilliams, 2011.

4. Looking closely at specific situations

Rather than stopping at a statement such as "My relationships are exhausting," the therapist can explore a recent event:

"What happened? What did you feel? What did you expect from the other person? How did you respond? What happened next?"

Several situations can then be compared to see what repeats and what differs. Patterns across different situations may provide a firmer basis for understanding than a single incident.

5. Developing and discussing an initial formulation

The therapist offers an understanding in accessible language and listens to what the person finds accurate and what needs revision.

For example: "It seems that disagreeing with important people brings up a fear of losing them. You hold back from expressing what you want, then feel upset with them. Does that fit your experience, or are we missing something?"

The formulation is a clinical hypothesis open to revision. Professional literature emphasizes a tentative approach, efforts to develop a shared understanding, and connecting interpretation to what is happening in the present. Summers & Martindale, 2013.

6. Turning understanding into a plan that can be reviewed

Priorities, goals and ways of working are discussed, followed by reviews of progress: what has changed in symptoms, relationships and the person's ability to manage previously troubling situations?

Assessment continues over time. New information may call for changes to the understanding or the treatment plan.

Examples of what this understanding can add

Example one: finding it difficult to say "no"

"Hind" agrees to extra requests from colleagues, then returns home exhausted and angry. In theory, she knows how to decline, but feels intensely guilty when she tries.

Exploring a particular incident, she says: "If I refuse, they will think I am selfish and won't want me around."

One possibility to explore is that refusing feels like risking acceptance. Agreeing may protect the relationship while leaving her own needs unmet.

Before adopting this understanding, the therapist needs to know what actually happens at work. Are employees penalized for refusing? Does this difficulty recur with friends and family, or only in the workplace?

If a broader pattern emerges, treatment may address recognizing her wishes, tolerating guilt and expressing boundaries, while also responding to real pressures.

Example two: explaining a painful experience while struggling to reach the feeling

"Rashid" describes his separation from his wife precisely. He explains the disagreements and analyzes both their personalities. Asked how he feels, he replies: "It all makes sense logically."

Analysis may be protecting him from grief or a sense of need. It may also be his usual way of expressing himself, or he may need more time to feel safe, or the question may have come too early.

A useful next step is exploration: what happens inside when he stops explaining the facts? What makes speaking about feelings difficult?

A way of speaking alone is insufficient to establish that a particular defense is present.

Example three: fear of disagreeing with the therapist

"Noura" says she always agrees with the therapist's suggestions, then reveals that she was not convinced by some of them: "I was afraid you would think I didn't want to get better."

They can explore whether this expectation occurs in other relationships and whether the therapist's manner has actually made disagreement difficult.

Discussing the situation openly may allow Noura to experience disagreeing while the relationship remains safe and respectful.

These examples illustrate possible understandings. They are not rules linking a single behavior to a specific psychological cause.

What role does the therapeutic relationship play in diagnosis?

Expectations and feelings familiar from other relationships may emerge in therapy: anticipating criticism, fearing rejection or repeatedly needing reassurance that the other person cares. Transference is a concept used to understand these dimensions when they develop in the relationship with the therapist.

The therapist also attends to their own responses, some of which are discussed under countertransference. These require reflection, since they may also be influenced by the therapist's personality, circumstances and way of interacting.

Using the therapeutic relationship as a source of understanding therefore involves considering both people's contributions and checking the facts. Cancelling a session, for example, may reflect financial or work circumstances; it is not enough on its own to conclude that someone is avoiding treatment. Attention to recurring patterns and the therapeutic relationship is central to psychodynamic work. Shedler, 2010; Summers & Martindale, 2013.

Does talking about personality mean there is a personality disorder?

A tendency toward perfectionism, reserve or reliance on others is insufficient to diagnose a personality disorder. Assessment needs to consider a pattern's severity, flexibility, persistence and effect on the person's life.

It helps to distinguish:

Personality style: recurring traits and tendencies in thinking, feeling and relationships.
Personality disorder: a diagnosis requiring clinical assessment against defined criteria.
Level of personality organization: a theoretical and clinical concept describing aspects of identity integration, defenses and the relationship to reality.

In particular, "borderline personality organization" does not automatically mean "borderline personality disorder." The former is a broader concept within a model of personality organization; the latter is a specific diagnosis. Doering et al., 2013.

Are there scientific assessment tools?

Assessment relies on the clinical interview and may be supported by structured or semi-structured tools, depending on need and the clinician's training.

Examples include the STIPO-R for aspects of personality organization and defense assessment methods such as the DMRS. These tools help organize observations and provide clearer rating criteria. STIPO-R manual; Lingiardi & Madeddu, 2025.

A study of the German version of the STIPO involving 122 psychiatric patients found results supporting its reliability and validity in the sample studied.

The implications are specific: support for measuring certain aspects of personality does not establish that every psychodynamic interpretation is correct. Nor does it establish, by itself, that using a particular tool improves treatment outcomes for everyone. Findings from one language version should not be generalized to another without appropriate validation. Doering et al., 2013.

How can this understanding help treatment?

Assessment is useful when it informs concrete decisions: where to begin, how to communicate, how much support to provide, when to explore, and which goals fit the person.

Someone who struggles to soothe strong emotions may need help building the capacity to tolerate and regulate feelings. Someone able to reflect on their experience but consistently avoiding particular feelings may benefit from gradually exploring that avoidance. Understanding personality can help tailor the therapist's interpersonal approach, the tone of interventions and the initial focus of work. McWilliams, 2011.

Goals may include symptom relief, understanding relationship patterns, expressing needs, tolerating differences and making decisions more consistent with the person's wishes and values. Psychodynamic literature includes the development of psychological capacities among treatment goals, while outcomes vary between individuals. Shedler, 2010.

Frequently asked questions

Do I need to remember my childhood in detail?

You can begin with what you know about your current life. The past can be helpful when relevant information is available. Current difficulties do not require assuming a forgotten event or filling gaps in memory with interpretations.

Can my situation be understood in one session?

A first session may allow an initial impression and identification of urgent needs. Understanding longstanding patterns requires sufficient information, and a formulation may change as meetings continue. There is no single number of sessions that suits every case.

What if I disagree with the therapist's interpretation?

Say so. Disagreement is important information that can help revise the understanding and the way you communicate. Useful questions include: what observations support this interpretation, and what alternatives are possible?

Does this approach explain everything through childhood?

Psychodynamic understanding includes present relationships and actual circumstances. The workplace or a current relationship may directly contribute to distress. Exploring history can help when relevant, while attending to present realities remains necessary. Summers & Martindale, 2013.

How can I tell whether the assessment is helpful?

It should clarify what is happening, what you will work on, and how progress will be reviewed. You can ask the clinician about their approach and experience, treatment goals, how improvement is assessed, and the limits of confidentiality. National Institute of Mental Health.

Psychodynamic diagnosis is valuable when it helps a person understand an experience that has felt confusing or contradictory and gives the therapist a clearer basis for working with them. That understanding remains open to correction and development as the person's life and capacity for change become clearer.

Scientific references

Lingiardi, V., & McWilliams, N. (Eds.). (2026). Psychodynamic Diagnostic Manual: PDM-3 (3rd ed.). Guilford Press. Book and third-edition introduction.
McWilliams, N. (1999). Psychoanalytic Case Formulation. Guilford Press. Book.
McWilliams, N. (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). Guilford Press. Chapter on the value of diagnosis.
Clarkin, J. F., Caligor, E., Stern, B., & Kernberg, O. F. (2021 revision). Manual for the Structured Interview of Personality Organization–Revised (STIPO-R). Manual.
Lingiardi, V., & Madeddu, F. (2025). Revisiting defense mechanisms in contemporary clinical practice: Evidence and perspectives. Research in Psychotherapy: Psychopathology, Process and Outcome, 28(3). Article.
Kessler, H., Stasch, M., & Cierpka, M. (2013). Operationalized psychodynamic diagnosis as an instrument to transfer psychodynamic constructs into neuroscience. Frontiers in Human Neuroscience, 7, 718. Article.
Summers, A., & Martindale, B. (2013). Using psychodynamic principles in formulation in everyday practice. Advances in Psychiatric Treatment. Article.
Doering, S., et al. (2013). Reliability and validity of the German version of the Structured Interview of Personality Organization (STIPO). BMC Psychiatry, 13, 210. Study.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. Article.
American Psychoanalytic Association. What Is Psychoanalytic or Psychodynamic Psychotherapy? Source.
National Institute of Mental Health. Psychotherapies. Source.

Related reading: Psychodynamic therapy · Your first session · Psychological library