Convergent and discriminant validity of overall defensive functioning

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder

OBJECTIVE

We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths.

METHOD

We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM).

RESULTS

A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment.

CONCLUSION

Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

Personality, Defenses, Mentalization, and Epistemic Trust Related to Pandemic Containment Strategies and the COVID-19 Vaccine: A Sequential Mediation Model

BACKGROUND

The COVID-19 pandemic has considerably influenced all domains of people's lives worldwide, determining a high increase in overall psychological distress and several clinical conditions. The study attempted to shed light on the relationship between the strategies adopted to manage the pandemic, vaccine hesitancy, and distinct features of personality and mental functioning.

METHODS

The sample consisted of 367 Italian individuals (68.1% women, 31.9% men; M age = 37, SD = 12.79) who completed an online survey, including an instrument assessing four response styles to the pandemic and lockdown(s), the Personality Inventory for DSM-5-Brief Form, the Defense Mechanisms Rating Scales-Self-Report-30, the Reflective Functioning Questionnaire, and the Epistemic Trust, Mistrust, Credulity Questionnaire.

RESULTS

Maladaptive response patterns to pandemic restrictions were related to dysfunctional personality traits, immature defense mechanisms, poor mentalization, and epistemic mistrust or credulity. Moreover, more severe levels of personality pathology were predictive of an extraverted-maladaptive response style to health emergency through the full mediation of low overall defensive functioning, poor certainty of others' mental states, and high epistemic credulity.

CONCLUSIONS

Recognizing and understanding dysfunctional psychological pathways associated with individuals' difficulties in dealing with the pandemic are crucial for developing tailored mental-health interventions and promoting best practices in healthcare services.

Changes in Defense Mechanisms in Mothers From Pregnancy to 2 Years Postpregnancy

ABSTRACT

The objective of this study was to assess changes in maternal defensive functioning from the third trimester of pregnancy to 2 years postpregnancy. A community sample of at-risk mothers ( N = 84; non-White [61%], unmarried [67%], high school or less education [72%], and income less than $20,000 [50%]) were recruited for this longitudinal study. Mothers responded to a semistructured interview during pregnancy and at 2 years postpregnancy about the parent-infant relationship; interview transcripts were coded using the Defense Mechanism Rating Scale (DMRS). Results indicated a significant increase in both total defense mechanisms used and the relative percentage of immature defense mechanisms used over time. A significant decrease in the relative percentage of healthy/adaptive defenses was noted. When all seven levels of defenses of the DMRS were assessed, it was an increase in minor image-distorting defenses, mechanisms that supported vulnerable self-esteem, that accounted for most of the change in immature defenses. Stability coefficients of defense mechanisms were reported, with large effect sizes, for overall defensive functioning, and mature and immature defenses over a 2-year period. These findings lend support to the importance of assessing defense mechanisms to better understand stressful life transitions in mothers.

Change in Defensive Functioning Following Group Psychodynamic-Interpersonal Psychotherapy in Women With Binge-Eating Disorder

We examined change in defensive functioning following group psychodynamic-interpersonal psychotherapy (GPIP) for binge-eating disorder (BED) compared to a waitlist control. We hypothesized that defensive functioning will improve to a greater extent at posttreatment for those in GPIP compared with those in a waitlist control condition. Participants were women with BED assigned to GPIP (n = 131) or a waitlist control (n = 44) condition in a quasi-experimental design. Those who received GPIP had significantly greater improvements in defensive functioning from pretreatment to six months posttreatment compared to the control group. GPIP may be effective for improving defensive functioning in individuals with BED. A randomized controlled trial is needed to confirm that GPIP is efficacious for addressing defensive functioning among women with BED.

Psychometric Properties of the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30): Internal Consistency, Validity and Factor Structure

Assessment of defense mechanisms has a longstanding history within the clinical psychology and psychopathology literature. Despite their centrality to clinical practice, there are few self-report measures that assess defenses and, those that do exist, have limitations in addressing individual defenses and levels of defensive functioning. To address this need, we investigated the psychometric properties of the Defense Mechanisms Rating Scale - Self-Report - 30 item (DMRS-SR-30) with a global, community sample of 1,539 participants who responded to an online survey about distress and coping. Exploratory factor analysis found a three-factor model for the DMRS-SR-30 - mature, mental inhibition and avoidance, and immature-depressive. Internal consistency was high for the Overall Defensive Functioning (ODF) and the three extracted factors with coefficient alphas ranging from .75 to .90. Examination of concurrent validity with a commonly used measure of defensive functioning found significant relationships in the predicted directions. The group of immature defenses had the strongest concurrent validity (r = .50). Finally, correlations with external criteria - including psychological distress and adverse childhood experiences - supported the convergent and discriminant validity of the DMRS-SR-30. The three factor structure of the DMRS-SR-30 has good psychometric properties. Limitations and directions for future research, as well as clinical implications, are described.

Assessing children's defense mechanisms with the Defense Mechanisms Rating Scales Q-sort for Children

Defense mechanisms are unconscious and automatic psychological processes that serve to protect the individual from painful emotions and thoughts. There is ample evidence from the adult psychotherapy and mental health literature suggesting the salience of defenses in the maintenance and amelioration of psychological distress. Although several tools for the assessment of children's defenses exist, most rely on projective and self-report tools, and none are based on the empirically derived hierarchy of defenses. This paper outlines the development of the defense mechanisms rating scale Q-sort for children (DMRS-Q-C), a 60-item, observer-rated tool for coding the use of defenses in child psychotherapy sessions. Modifications to the Defense Mechanisms Rating Scale Q-Sort for adults to create a developmentally relevant measure and the process by which expert child psychotherapists collaborated to develop the DMRS-Q-C are discussed. A clinical vignette describing the child's defensive functioning as assessed by the innovative DMRS-Q-C method is also reported. Finally, we provide an overview of forthcoming research evaluating the validity of the DMRS-Q-C.

Psychological Adaptive Mechanism Maturity, Age, and Depression Symptoms in Advanced-Stage Cancer Patients

Background: Previously, we reported that the maturity of Psychological Adaptive Mechanism (PAM; alternatively, ego defense mechanism) endorsement, but not depression symptom severity, predicted 5-year survival rates in adult cancer patients and that study controlled for age as a significant variable. In this investigation, we hypothesized that greater PAM maturity would correlate significantly with age and with fewer depression symptoms in a larger sample.

Methods: In this cross-section study, adult cancer outpatients (N=293) completed the Defense Style Questionnaire (DSQ), the Beck Depression Inventory (BDI), and provided additional clinical data. Spearman’s correlation and multiple regression modeling provided statistical tests of the study hypotheses.

Results: Contrary to our hypothesis, DSQ PAM maturity endorsement did not correlate significantly with increasing age. Greater PAM maturity ratio on the DSQ (p<0.0001) and current antidepressant use (p<0.05), however, both provided inverse associations with total BDI symptom frequency (p<0.01). Age was inversely associated with BDI mood (p<0.0001) and somatic scores (p<0.04). Items that worsened BDI symptom frequency included self-reported mood-altering anti-cancer medications and any psychiatric history. Cancer stage, time since diagnosis, and chemotherapy treatment did not correlate with DSQ or BDI scores. Multiple regression analysis found that the correlated items accounted for 17.2% of the variance in mood symptoms and 4.9% in somatic symptoms. Specifically, adaptive maturity and age associated with fewer depression symptoms, while cancer medications affecting mood, and a previous psychiatric history each predicted higher frequency of depression scores.

Conclusion: The results suggest that PAM maturity likely predicts fewer depression symptoms while younger age associates with more depression symptoms in this clinical sample. Centrally, acting cancer medications, such as glucocorticoids, and any history of psychiatric disorder correlated with increased depression symptom frequencies. In this cross-section study, antidepressant medications indicated higher frequencies of depressive symptoms, likely reflecting their use in persons previously diagnosed with depression. Further research should target factors that improve PAM maturity as a potential treatment target, especially in younger age groups.

Defensive Functioning of Individuals Diagnosed With Gender Dysphoria at the Beginning of Their Hormonal Treatment

Defense mechanisms are relevant indicators of psychological functioning and vulnerability to psychopathology. Their evaluation can unveil individuals' unconscious strategies for mediating reactions to emotional conflict and external stressors. At the beginning of their journey toward gender reassignment, individuals diagnosed with gender dysphoria (GD) may experience conflict and stressful experiences that trigger a wide range of defense mechanisms. Mature defenses may strengthen these individuals as they travel along this important path, while neurotic and immature defenses may exacerbate their body dissatisfaction (BD) and hinder their processing of change. Only a few studies have investigated self-reported defensive functioning in transgender people, finding a higher frequency of maladaptive defense mechanisms relative to controls. The present study was the first to apply an in-depth clinician-rated tool to assess the entire hierarchy of defense mechanisms within a sample of transgender people. Defensive functioning and personality organization were assessed in 36 individuals diagnosed with GD (14 trans women, 22 trans men, mean age 23.47 years), using the Defense Mechanisms Rating Scales (Perry, 1990) and the Shedler-Westen Assessment Procedure-200 (Shedler et al., 2014). Body uneasiness was assessed using the Body Uneasiness Test (BUT; Cuzzolaro et al., 2006). The findings showed that defensive functioning correlated positively with healthy personality functioning and negatively with BD. Compared to cisgender controls, participants with GD who presented greater defensive functioning were found to be more immature and to demonstrate significant differences in many levels of functioning. The clinical implications of the results suggest that psychological interventions aimed at improving defensive functioning in individuals with GD will be important in helping them manage the challenges posed by their gender transition.

Defense Mechanisms, Gender, and Adaptiveness in Emerging Personality Disorders in Adolescent Outpatients

The present study focused on demographic and personality differences in the use of 30 defense mechanisms in adolescents with personality psychopathology and explored the hierarchical organization of personality traits based on the adaptiveness of defensive functioning. A total of 102 self-referred adolescent outpatients were interviewed and assessed on defense mechanisms and personality traits using the Defense Mechanisms Rating Scales and the Shedler-Westen Assessment Procedure 200 for Adolescents, respectively. Age and gender differences were found throughout the hierarchy. Pearson's correlations revealed a hierarchical organization of emerging personality disorders (PDs) in adolescence. More adaptive defenses were clearly associated with healthier personality style, whereas more pathological personality styles such as those with borderline traits were characterized by more rigid and maladaptive defenses. Dissociation was also associated with maladaptive personality types. Identifying the defenses associated with emerging personality disorders may inform the unconscious function of defense mechanisms in specific PDs. The systematic assessment of defense mechanisms might also help therapists to monitor changes during treatment.

Preliminary Reliability and Validity of the DMRS-SR-30, a Novel Self-Report Measure Based on the Defense Mechanisms Rating Scales

Defense mechanisms are psychological factors that influence emotional distress and quality of life. There are a number of measures assessing the construct of defense mechanisms, but only few available instruments reflect the gold-standard theoretical hierarchical organization of defenses. We report on the development of a novel 30 item self-report questionnaire, the DMRS-SR-30, based on the parent instrument, the Defense Mechanism Rating Scales (DMRS). This study tested preliminary reliability and validity of the Italian version of the DMRS-SR-30. We first extracted 30 items from the DMRS Q-sort version (DMRS-Q) and adapted them for a self-reported format. We then applied the DMRS quantitative scoring algorithms to provide proportional scores for the 28 individual defenses and summary scores for seven defense levels and overall defensive functioning (ODF) scores. A dynamic interview was used for assessing participant's defense mechanisms with the observer-rated DMRS and DMRS-Q. We examined internal consistency of the scales along with criterion, concurrent, convergent and discriminant validity among participants (N = 94) who completed the DMRS-SR-30, SCL-90, BDI, and IES-R. Results showed very good internal consistency for ODF (Cronbach's alpha = .890) and the high adaptive defense level, whereas some subscales with few items had lower values. Correlation analyses between DMRS-SR-30 and the two DMRS-based observer-rated measures showed very good criterion and concurrent validity for ODF and moderate to high for defense levels subscales. Correlations between the DMRS-SR-30 ODF and SCL-90 GSI, BDI and IES=R (r = -.456, r= -.540, r = -.402, respectively, all p <.001), indicated good convergent validity. Despite the well-known limitations of self-report methods of psychodynamic phenomena, self-report measures are highly practicable for assessing large samples. The DMRS-SR-30 is the first self-assessed measure describing the whole hierarchy of 28 defense mechanisms and providing scores for ODF, defensive categories, defense levels, and individual defenses. Preliminary examination of the Italian version of the DMRS-SR-30 showed promising results of internal consistency, criterion and concurrent validity, and convergent validity and of the measure. Further validation is needed to confirm these findings and explore other aspects of validity and reliability.

Defense mechanisms in adolescents at high risk of developing psychosis: an empirical investigation

Research within psychotherapy and psychopathology frameworks has been inspired by the central concept of defense mechanisms, which play a pivotal role in psychoanalysis. Defense specificities have only recently been studied systematically in the context of several clinical diagnoses. The present study aimed to explore the specificities of defense mechanisms in adolescents at ultra-high risk of developing psychosis and test the relationship between defensive functioning and attenuated psychotic symptoms. Twenty-six adolescent inpatients at ultra-high risk of developing psychosis and a matched clinical control group of inpatients not at risk of psychosis were interviewed. Two observer-rater methods, the Defense Mechanism Rating Scales and the Psychotic-Defense Mechanism Rating Scales were applied to interview transcripts to assess the individual use of defenses. Ultra-high-risk patients demonstrated lower defense mechanisms (i.e., total instances of defense mechanisms observed) and lower overall adaptiveness of the defenses presented. When specific differences between groups were observed, psychotic defenses were the sole defenses that could partially discriminate between ultra-high-risk and not at-risk patients. Regarding the relationship between defense mechanisms and subthreshold psychotic symptoms, psychotic defenses were associated with negative and disorganization symptoms, rather than with positive symptoms. The psychological vulnerability of ultra-high-risk patients is discussed and treatment implications for psychotherapy with such challenging patients are addressed.

Change in Defense Mechanisms and Depression in a Pilot Study of Antidepressive Medications Plus 20 Sessions of Psychotherapy for Recurrent Major Depression

Treatment studies of major depression commonly focus on symptoms, leaving aside change in putative psychological risk factors. This pilot study examines the relationship between changes in eight depressive defenses and depressive symptoms. Twelve adults with acute recurrent major depression were given antidepressive medications and randomized to 20 sessions of either cognitive behavioral therapy or dynamic psychotherapy and followed for 1 year. Defenses were assessed using the Defense Mechanism Rating Scales (DMRS) and Defense Style Questionnaire (DSQ) at intake, termination, and 1-year follow-up. Depression improved highly significantly on both the Hamilton Rating Scale for Depression and Beck Depression Inventory, respectively, eight (67%) and nine (75%) patients attained recovery by 1 year. Depressive defenses improved significantly by termination (mean ES = 0.97; 95% confidence interval, 0.30-2.16), but retrogressed somewhat by 1 year. A mean of 12.17% (SD = 10.60) depressive defenses remained; only five subjects (50%) attained normative levels. Although causal relationships were not established, depressive defenses are promising candidates for mediating treatment effects on outcome of major depression.

The Role of Defense Mechanisms in Emerging Personality Disorders in Clinical Adolescents

Background: Defensive functioning is related to overall mental functioning and personality traits in adults but only few studies investigated the role of defenses in adolescence. The present study analyzed the use of defense mechanisms in clinical adolescents to test how defensive functioning is related to age, gender, and personality traits.Design: 102 self-referred outpatients were interviewed using the Clinical Diagnostic Interview (CDI). Defense mechanisms and personality profile were assessed using the Defense Mechanisms Rating Scale (DMRS) and the Shedler-Westen Assessment Procedure-200 for Adolescence (SWAP-200-A) respectively.Findings: Multivariate analysis of variance showed significant age and gender differences in clinical adolescents; while younger teenagers used more immature defenses, older adolescents scored significantly higher in high-neurotic and mature defenses. Girls showed higher use of minor image distortion and neurotic defenses, whereas boys recurred more frequently to obsessional level defenses. Neither age nor gender differences were found for narcissistic defense level. Significant correlations between personality disorders and specific defenses were found for all personalities with sufficient base rate, with the exception of paranoid, schizotypal, and schizoid personalities.Conclusions: In line with previous studies we confirmed the hypothesis of an ontogenetic line of development of defense mechanisms. In addition, the present study found that age and gender differences in adolescence are related to the use of specific defenses that contribute to the development of the personality and various psychological capacities. Several clinical implications are linked to the systematic investigation of defense mechanisms in youth, although further studies are required to confirm these findings.

Physicians' emotion regulation during communication with advanced cancer patients

OBJECTIVE

In cancer care, optimal communication between patients and their physicians is, among other things, dependent on physicians' emotion regulation, which might be related to physicians' as well as patients' characteristics. In this study, we investigated physicians' emotion regulation during communication with advanced cancer patients, in relation to physicians' (stress, training, and alexithymia) and patients' (sadness, anxiety, and alexithymia) characteristics.

METHODS

In this study, 134 real-life consultations between 24 physicians and their patients were audio-recorded and transcribed. The consultations were coded with the "Defence Mechanisms Rating Scale-Clinician." Physicians completed questionnaires about stress, experience, training, and alexithymia, while patients completed questionnaires about sadness, anxiety, and alexithymia. Data were analysed using linear mixed effect models.

RESULTS

Physicians used several defence mechanisms when communicating with their patients. Overall defensive functioning was negatively related to physicians' alexithymia. The number of defence mechanisms used was positively related to physicians' stress and alexithymia as well as to patients' sadness and anxiety. Neither physicians' experience and training nor patients' alexithymia were related to the way physicians regulated their emotions.

CONCLUSIONS

This study showed that physicians' emotion regulation is related to both physician (stress and alexithymia) and patient characteristics (sadness and anxiety). The study also generated several hypotheses on how physicians' emotion regulation relates to contextual variables during health care communication in cancer care.

What Defense Mechanisms Do Therapists Interpret In-Session?

One of the key technical guidelines outlined by psychodynamic theorists and clinicians is for therapists to interpret a patient's most prominent defenses (Greenson, 1967; Langs, 1973). However, a debate exists about what constitutes a patient's most prominent defense and which defenses therapists actually choose to interpret in-session. This study aimed to shed light on this debate by examining 35 psychotherapy sessions (18 high alliance and 17 low alliance dyads) of individuals in therapy at a university counselling center. The analysis focused on comparing the patients' most prominent defenses and the range of defenses they utilized, and the therapists' most prominent interpretation level as well as the range of interpretation level. Paired sample t-tests showed no significant mean difference between sessions with low and high alliance scores in patient defense levels (e.g., frequency and range) and therapist interpretation levels (e.g., frequency and range). Significant differences were found between the range of patient defense levels and the range of therapist interpretation levels. Correlational analyses showed no significant relationship between patient defense levels and therapist interpretation levels on both the frequency and range levels. Clinical implications of these results, and directions for future research are discussed.

Understanding Defense Mechanisms

Understanding defense mechanisms is an important part of psychotherapy. In this article, we trace the history of the concept of defense, from its origin with Freud to current views. The issue of defense as an unconscious mechanism is examined. The question of whether defenses are pathological, as well as their relation to pathology, is discussed. The effect of psychotherapy on the use of defenses, and their relation to a therapeutic alliance is explored. A series of empirical research studies that demonstrate the functioning of defense mechanisms and that support the theory is presented. Research also shows that as part of normal development, different defenses emerge at different developmental periods, and that gender differences in defense use occur.

Changes in Defense Mechanism Functioning During Group Therapy for Binge-Eating Disorder

OBJECTIVE

This study examined change in defensive mechanism functioning during group psychodynamic interpersonal psychotherapy (GPIP) for women with binge-eating disorder (BED).

PROCEDURE

Women with BED (N = 85) received 16 weeks of GPIP. Five group therapy sessions (sessions 1, 3, 8, 12, and 16) from each of the 12 groups were video recorded and transcribed. Participants were rated on an observer-based measure of defensive functioning, the Defense Mechanism Rating Scale (DMRS). Symptom outcomes were assessed pre- and posttreatment.

RESULTS

Overall defensive functioning (ODF) scores improved significantly during group treatment, with specific defense level improvements in high adaptive, major image distorting, and action defenses. The linear increase in ODF mediated a decrease in binge-eating episodes and depressive symptoms. Reverse mediation was also noted. A cubic growth curve best modeled ODF data such that ODF improved in the early stage, followed by a slower rate of improvement in the middle stage, and a further increase in rate of improvement at the end of treatment.

DISCUSSION

Change in defense mechanism functioning may be an important aspect of group psychotherapy that is related to improved symptoms for women with BED who receive GPIP. The cubic trend that represented nonlinear growth in ODF is consistent with psychodynamic theory and a stage model of psychotherapy.

Intellectualization and its lookalikes

The present paper offers a conceptual review and clarification of the theoretical construct of intellectualization, a popular concept both in the psychoanalytic literature and in the culture at large. It is shown that in the contemporary literature, intellectualization is inconsistently conceptualized. A review of the history of the concept reveals two distinct threads of meaning, which are developed and clarified. Intellectualization can best refer either to a variant of the more basic defense of isolation of affect, or to the psychological translation of emotional issues into intellectual terms. Several clinical misunderstandings of intellectualization are presented in a cautionary light.

Therapeutic interaction with an older personality disordered patient

This study reflects an assessment of the relationship between change in defensive functioning and change in the therapeutic interaction during an eight-year treatment episode of an older personality disordered woman. The patient, Ms. Q, possessed schizoid, avoidant, and depressive personality disorders as well as major depression as assessed by the Millon Clinical Multiaxial Inventory-III (MCMI-III). At the end of the treatment episode, Ms. Q still possessed an avoidant personality disorder and significant depressive personality traits but no longer possessed clinically significant schizoid traits or major depression. Ms. Q made significant positive change in her adaptive defensive functioning as assessed by the Defense Mechanism Rating Scale (DMRS). Through time-series analysis it was discovered that positive change in adaptive defenses was predicted by increases in a specific type of therapeutic interaction as assessed by the Psychotherapy Q Sort (PQS). In this therapeutic interaction the therapist in a didactic and advice-giving manner highlighted the patient's role in a problem in a clear and coherent way that could be perceived as tactless. Time-series analysis revealed a reciprocal relationship in which positive changes in adaptive defenses predicted further increases in that particular quality of therapeutic interaction.

Development of a Q-sort version of the Defense Mechanism Rating Scales (DMRS-Q) for clinical use

This report focuses on the need to provide clinicians with a reliable and valid measure for detecting patient defense mechanisms "inside psychotherapy." To avoid the limitations of existing methods, we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in psychotherapy and its scores correlate significantly with various aspects of mental functioning, making it potentially available for the psychotherapy process and outcome research as well. We report the results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change both in quantitative scores and in the literary Defensive Profile Narrative.

Construction and preliminary validation of a dictionary for cognitive rigidity: linguistic markers of overconfidence and overgeneralization and their concomitant psychological distress

Fanaticism and extremism are increasingly recognized as seminal to psychopathology and distress, especially considering the increase in political unrest and violence over the last decade. In the psychopathological literature, however, the cognitive style associated with extremism and overgeneralization has long been recognized as a risk factor for emotional distress, leading to both externalizing behavior (e.g. aggression) and internalizing pathology (e.g. depression). Despite its recognized importance, however, virtually no standardized measures of this cognitive style exist. Since direct inquiry about a respondent's Cognitive Rigidity, is likely to be biased, a text-analytical measure of extremism in spontaneous autobiographical narratives is proposed. In contrast to self-reports, naturally occurring speech often suggests cognitive proclivities towards overgeneralization, overconfidence or extremization. In this study, spoken autobiographical narratives were elicited from 483 participants, and contrasted with extensive mental health information using a hierarchical concordanced-keyword technique. The resulting corpus-based dictionary is context-sensitive, and exhibits significant correlations with measures of negative emotionality, with minimal association with response bias measures.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Defensive Functioning Scale: a validity study

OBJECTIVE

We assess the convergent and predictive validity of the Defensive Functioning Scale (DFS) with measures of life events, including childhood abuse and adult partner victimization; dimensions of psychopathology, including axis I (depressive) and axis II (borderline personality disorder) symptoms; and quality of object relations.

METHOD

One hundred and ten women from a university-based urban primary care clinic completed a research interview from which defense mechanisms were assessed. The quality of object relations was also assessed from interview data. The women completed self-report measures assessing depression, borderline personality disorder symptoms, childhood physical and sexual abuse, and adult partner physical and sexual victimization.

RESULTS

Inter-rater reliability of the scoring of the DFS levels was good. High adaptive defenses were positively correlated with the quality of object relations and pathological defenses were positively correlated with childhood and adult victimization and symptom measures. Although major image distorting defenses were infrequently used, they were robustly correlated with all study variables. In a stepwise multiple regression analysis, major image distorting defenses, depressive symptoms, and minor image distorting defenses significantly predict childhood victimization, accounting for 37% of the variance. In a second stepwise multiple regression analysis, borderline personality disorder symptoms and disavowal defenses combined to significantly predict adult victimization, accounting for 16% of the variance.

CONCLUSIONS

The DFS demonstrates good convergent validity with axis I and axis II symptoms, as well as with measures of childhood and adult victimization and object relations. The DFS levels add nonredundant information to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition beyond axis I and axis II.

Early change in defence mechanisms and coping in short-term dynamic psychotherapy: relations with symptoms and alliance

Several patient-related variables have already been investigated as predictors of change in psychodynamic psychotherapy. Defensive functioning is one of them. However, few studies have investigated adaptational processes, encompassing defence mechanisms and coping, from an integrative or comparative viewpoint. This study includes 32 patients, mainly diagnosed with adjustment disorder and undergoing time-limited psychodynamic psychotherapy lasting up to 40 sessions, and will focus on early change in defence and coping. Observer-rater methodology was applied to the transcripts of two sessions of the first part of the psychotherapeutic process. It is assumed that the contextual-relational variable of therapeutic alliance intervenes as moderator on change in adaptational processes. Results corroborated the hypothesis, but only for coping, whereas for defences, overall functioning remained stable over the first 20 sessions of psychotherapy. These results are discussed within the framework of disentangling processes underlying adaptation, i.e., related to issues on trait and state aspects, as well as the role of the therapeutic alliance.

Differentiation of depression and anxiety groups using defense mechanisms

We examined whether participants in depressed and anxious groups could be classified correctly using observer and self-report measures of defense mechanisms. A sample of 1182 university students completed the Personality Assessment Inventory and those scoring in the clinical range on either depression or anxiety indices were selected for participation. In total, 25 participants met criteria for the depressed group and 94 met criteria for the anxious group. Individual defense scores from the Defense-Q and the Defense Style Questionnaire were separately entered into 2 stepwise discriminant analyses. After cross-validation, the Defense-Q and Defense Style Questionnaire analyses classified participants with 75.0% and 71.3% accuracy, respectively. The results indicated that depression and anxiety groups can be significantly differentiated by defense use alone. Important differences in defensive functioning between these groups were confirmed and differences between observer and self-report measures of defenses mechanisms and current challenges in defense research were highlighted.

Defense mechanisms and Major Depressive Disorder in African American women

This study explored differences in defense use between a group of predominantly African American women diagnosed with Major Depressive Disorder (MDD; n = 20) and a healthy control sample (n = 20), both from a primary care medical clinic. Patients completed the Patient Health Questionnaire to assess DSM-IV diagnoses and underwent video-recorded interviews, which were assessed for defenses using the Defensive Functioning Scale from the DSM-IV. Groups were compared for differences in overall defensive functioning, defense levels, and individual defenses using independent samples t tests. Results showed that the MDD group scored higher on mental inhibition, minor image distorting, and major image distorting defense levels as well as the individual defenses devaluation, dissociation, and isolation. The control group scored higher on the overall defensive functioning and the individual defense anticipation. The results also showed a trend toward the MDD group scoring higher on the disavowal defense level and the individual defense splitting.

Specificities of defense mechanisms in bipolar affective disorder: relations with symptoms and therapeutic alliance

Defense mechanisms as a central notion of psychoanalysis have inspired various levels of interest in research in psychotherapy and psychopathology. Defense specificities have only recently been investigated systematically with regard to several clinical diagnoses, such as affective and personality disorders. For the present study, 30 inpatients diagnosed with Bipolar Affective Disorder I (BD) were interviewed. An observer-rater method, the Defense Mechanisms Rating Scales (DMRS), applied to session-transcripts, of assessment of defenses was used. A matched, nonclinical control group was introduced. Defense specificities in BD encompass a set of 5 immature defenses, of which omnipotence is linked with symptom level. The level of the therapeutic alliance is predicted by mature defenses. These results are discussed with regard to the psychological vulnerability of BD, and treatment implications for psychodynamic psychotherapy with such challenging patients are evoked.

The Italian version of the Response Evaluation Measure-71

OBJECTIVE

The aim of the present study was to analyze the psychometric properties of the Italian version of the Response Evaluation Measure (REM-71), a 71-item self-report measure previously developed for the assessment of defenses in adults and adolescents. The authors also examined the differences in the use of defenses based on sex and age (early adolescence, late adolescence, and early adulthood), and the association between defenses, psychosocial health, and psychologic distress in a large community sample.

METHOD

The Italian version of REM-71 was obtained through back-translation and administered to 1648 (1020 female subjects, mean age = 19.5 years, SD = +/-5.77) community subjects, aged between 13 and 68 years, voluntarily recruited among high school and university students in Milan, Italy, and the surrounding area. All subjects completed a self-report measure to assess demographic variables and satisfaction with life. A subsample (n = 1197) completed the Italian version of the Symptom Checklist-90-Revised to assess symptoms of psychologic distress.

RESULTS

Results were highly consistent with those obtained in the original English version of the REM-71 and included satisfactory internal consistency of the measure. Factor analyses yielded 2 principal factors that showed overall stability across age and sex subgroups. Factor 1 and factor 2 defenses were significantly correlated, in line with theoretical expectations, with positive and negative aspects of various domains of life.

CONCLUSIONS

Results provide further support for the structure and validity of the REM-71 as a useful instrument for the assessment of defenses in adolescents and adults and suggest no major cross-cultural differences in the organization of these defenses.

Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: an exploratory study

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.

Cancer survival probability as a function of ego defense (adaptive) mechanisms versus depressive symptoms

Psychological treatment studies, uncontrolled for ego defense (adaptive) styles, report conflicting survival results. The authors hypothesized that "immature" adaptive styles and frequent depression symptoms would independently predict lower survival rates. This study followed 86 consecutive, mostly late-stage, cancer outpatients for up to 5 years; their survival data were analyzed in relation to the Beck Depression Inventory and the Defense Style Questionnaire scores at study entry. Cumulative survival probability curves contrasted the extreme cases: the most (N=15) to the least (N=21) depressed, and the "immature" (N=14) to the "mature" (N=16) adaptors. Depression did not separate the groups until 30 months after diagnosis. Ego defense style separated them at 8 months; by 18 months, the "immature" survival probability had dropped to 50%, versus 87% for the "mature." At 36 months, survival probabilities were 19% and 57%, respectively. These data direct clinical attention toward ego defense mechanisms as indicators of distress and lowered survival in cancer patients. They further suggest that the maturity of adaptive mechanisms must be controlled for in behavioral-treatment trials of cancer patients.

Personal strengths and traumatic experiences among institutionalized children given up at birth (Les Enfants de Duplessis--Duplessis' children): II: Adaptation in late adulthood

In a companion article, we retrospectively examined the childhood strengths and adverse experiences of a group of orphans given up at or near birth and raised in Quebec institutions. This article examines the relationship of their early experiences to functioning and symptoms in later adulthood. The same follow-up interview of 81 adults (41 women, 40 men) at a mean age of 59.2 years included assessments of their current symptoms and functioning. The mean adult Social and Occupational Functioning Score (57.8; 95% CI, 54.7-61.0) indicated moderate difficulty. Psychiatric symptoms were significantly higher than in a matched population survey sample from Quebec. Mean overall defensive functioning indicated a neurotic (inhibited) level. Total trauma and childhood strengths predicted adult outcomes, but childhood strengths moderated the effects of trauma. Institutionalization of children--if unavoidable--must build in effective safeguards against adverse experiences, especially among children with few strengths, and foster children's strengths to avoid impaired adult outcomes.

[Standardized and clinical evaluation of defense mechanisms: a critical review of 6 quantitative tools]

BACKGROUND

The defense mechanisms (DM) concept goes back to the foundation of psychoanalysis and is one of its theoretical cornerstones. Recently, with the introduction of this notion in an experimental item of categorical classification, DMs have become a new field in research and scientific communication. The increasing number of studies taking DMs into account matches the development of clinical evaluation scales that are easier to use than projective tests. To our knowledge, there is no comparative analysis of these tools.

OBJECTIVE

We aimed first to describe the operating mode and metrological qualities of the most recent scales and then to highlight the benefits and limitations of these clinical evaluation tools. Finally, this article aims to help clinicians choose a tool that is most convenient for their protocol.

METHOD

We introduce the following tools through a literature review: Defense Mechanism Inventory, Defense Mechanism Profile, Defense Style Questionnaire (DSQ), Defense Mechanism Rating Scale, Life Style Index, and Response Evaluation Measure.

CONCLUSION

Using clinical scales includes many limitations associated with the DM concept. Nevertheless, their feasibility and validity warrant their use. The DSQ stands out for its many qualities, but the other tools specificities are yet to be considered in regard to the chosen protocols.

Patient factors associated with delay in primary care among patients with head and neck carcinoma: a case-series analysis

BACKGROUND

Head and neck cancer patients are often diagnosed with advanced stage disease, while the location is easily accessible for examination or distinct symptoms are present. Professional delay in primary care affects tumour stage and survival. There has been little research on the role of the patient in delaying referral or diagnosis once the patient has visited a primary health care professional.

OBJECTIVES

Our aim was to identify patient-related factors which are associated with delay in primary care and the referral to hospital.

METHODS

Case-series analysis using semi-structured interviews combined with questionnaires was conducted among 306 consecutive patients newly diagnosed in a tertiary referral centre for head and neck oncology patients in The Netherlands. The main outcome measure was delay in returning to the GP or dentist after the first consultation. Logistic regression analyses were performed to test which patient-related variables made delay more likely.

RESULTS

155 patients (53%) were not referred or followed up after the first medical contact with the GP or dentist. Fifty per cent (n = 78) of them delayed returning to the health professional for more than three weeks. Patients were more likely to delay when they experienced voice change, were not familiar with head and neck cancer, were not suspicious of cancer or were generally not inclined to seek support.

CONCLUSIONS

Delay in returning to the health professional is partly dependent on patient-related factors. Therefore, patients should be educated about the possible meaning and expected time-course of the symptoms and be strongly advised to return, or be followed up, within three to four weeks if the symptoms do not disappear.

Clinical significance and patients' perceived change in four sessions of brief psychodynamic intervention: characteristics of early responders

This study investigated Tingey, Lambert, Burlingame, and Hansen's (1996) extension of Jacobson, Follette and Revenstorf's (1984) proposal for assessing clinical significance. Seventy (N=70) outpatients with/without Cluster C personality disorders treated with a brief psychodynamic intervention (BDI) were included in the study. Results showed that 33% of patients demonstrated clinically significant change on the Global Severity Index. Patients who improved reported more perceived subjective change, greater satisfaction with the treatment, and greater improvement on the Social Adjustment Scale than patients who did not improve (60%) or deteriorated (7%). Further analyses showed that clinical significance achieved in a four session ultra-brief therapy is associated with patient characteristics such as co-morbid personality disorders, level of defensive functioning, and specific interpersonal problems. Results were maintained at 3 month and 6 month follow-ups. Findings are discussed in reference to Howard's suggestions on remoralization and remission.

Childhood sexual abuse and adult defensive functioning

Differences in defensive functioning between those who reported a history of childhood sexual abuse (CSA) and those who did not was examined in a naturalistic treatment-seeking sample of adult outpatients (N = 67). Defensive functioning and childhood sexual abuse history were rated by clinicians and external raters utilizing the DSM-IV Defensive Functioning Scale and the Abuse Dimensions Inventory, respectively, based on information gathered as part of a larger therapeutic assessment. Individuals reporting a history of CSA were found to use more major image-distorting level defenses than the non-CSA group, and abuse severity was also related to greater use of major image-distorting level defenses. Those reporting a history of CSA relied more on defenses indicative of impairment in realistic perception of self and others. This defensive style likely contributes to the greater difficulties in interpersonal functioning and psychological problems in adulthood.

An empirical look at the Defense Mechanism Test (DMT): reliability and construct validity

Although the Defense Mechanism Test (DMT) has been in use for almost half a century, there are still quite contradictory views about whether it is a reliable instrument, and if so, what it really measures. Thus, based on data from 39 female students, we first examined DMT inter-coder reliability by analyzing the agreement among trained judges in their coding of the same DMT protocols. Second, we constructed a "parallel" photographic picture that retained all structural characteristic of the original and analyzed DMT parallel-test reliability. Third, we examined the construct validity of the DMT by (a) employing three self-report defense-mechanism inventories and analyzing the intercorrelations between DMT defense scores and corresponding defenses in these instruments, (b) studying the relationships between DMT responses and scores on trait and state anxiety, and (c) relating DMT-defense scores to measures of self-esteem. The main results showed that the DMT can be coded with high reliability by trained coders, that the parallel-test reliability is unsatisfactory compared to traditional psychometric standards, that there is a certain generalizability in the number of perceptual distortions that people display from one picture to another, and that the construct validation provided meager empirical evidence for the conclusion that the DMT measures what it purports to measure, that is, psychological defense mechanisms.

Clinical utility of the Defensive Functioning Scale in the assessment of depression

The Defensive Functioning Scale (DFS) and Overall Defensive Functioning score (ODF) have been used as reliable and valid measures of defense structure when applied to clinical narratives. This study aims to replicate and extend positive clinical validity data for the ODF in the assessment of depression and examine the relationship between specific defense levels of the DFS and depressive symptoms. Sixty-nine outpatients who completed the Symptom Checklist 90-Revised and Personality Assessment Inventory were rated on the DFS by trained clinicians. Lower (more maladaptive) scores on the ODF were significantly related to the presence and severity of patient-reported depression symptoms. Furthermore, depression symptoms were significantly related to both the presence of low-level action defenses and an absence of higher-range defenses in the mental inhibitions-obsessional level. Findings from this study provide further support for the clinical application and relevance of the DFS system; support the theory of defensive processes falling into a hierarchy of adaptive functioning; and, because of a naturalistic setting, are highly generalizable to real-world practice.

Empirical studies of defense style: relationships with psychopathology and change

The Defense Style Questionnaire (DSQ) is a widely used self-report measure of empirically derived groupings of defense mechanisms ranked on an adaptive hierarchy. A review of published studies indicates strong evidence that adaptiveness of defense style correlates with mental health and that some diagnoses are correlated with specific defense patterns-for example, borderline personality disorder with greater use of both maladaptive and image-distorting defenses and less use of adaptive defenses. For other diagnoses, the pattern of defenses is less clear but often reinforces theoretical formulations. Defense styles become more adaptive with improvement in symptoms, but intermediate defenses tend to be stable (traitlike) over time. Defenses are sometimes predictive of the quality of the therapeutic alliance. Although one might speculate that assessment of defenses can be useful in planning treatment, there are no studies supporting this hypothesis.

Psychological factors and patient delay in patients with head and neck cancer

There is a rising incidence of patients presenting with advanced cancer in the head and neck region. Late presentation may be due to a delay in seeking medical attention, which is sometimes surprisingly long. The aim of the present prospective study was to investigate the association between patient delay and the psychological factors of optimism, health hardiness, overall defensive functioning, coping styles and psychological distress in 277 patients with cancer of the head and neck. Significant correlations were found between patient delay and the psychological factors. Twenty-six percent of the patients waited more than three months before seeking medical attention and they reported less optimism (P = 0.0001), less health hardiness (P = 0.008), less active coping (P = 0.019) and less seeking support as a coping style (P = 0.017) than patients presenting within three months. Excessive drinkers (5+ alcoholic drinks/day) tended to show more delay than patients who did not drink or were moderate drinkers (0-2 drinks/day) or moderate-heavy drinkers (3-4 drinks/day). Together, the psychological factors could explain 25% of the variance of patient delay in excessive drinkers compared with 21% and 6% in moderate-heavy drinkers and non-drinkers to moderate drinkers, respectively. These results suggest that psychological factors affect health-care seeking behaviour. Health education aimed at the risk group of excessive drinkers should take psychological factors into account that influence their health behaviour.

Reliability and validity of the Japanese edition of the Defense Style Questionnaire 40

Defense styles have a close relationship with ego development and psychopathology. The purpose of the present paper was to examine the reliability and validity of the Japanese edition of the Defense Style Questionnaire (DSQ-40; Andrews et al. 1993). Six hundred and six Japanese university students (348 female) completed the DSQ-40 and Maudsley Personality Inventory (MPI). The neurotic tendency had positive correlations with immature and neurotic defense styles and a negative correlation with the mature defense style. The extroversion tendency had positive correlations with the mature and neurotic defense styles and a negative correlation with the immature defense style. There was a significant test-retest correlation for all items of the DSQ-40 (n = 284). The results show that the Japanese version of the DSQ-40 had concurrent validity with the MPI and a test-retest reliability of 2 months, although there was some doubt about the validity of the factor structure of the DSQ-40. Therefore, the DSQ-40 is a useful scale in Japan to measure ego development and ego function through defense styles.