Long-term changes in defense style among patients recovering from major depression

Profanity as a Self-Defense Mechanism and an Outlet for Emotional Catharsis in Stress, Anxiety, and Depression

Background

Swearing is an increasing trend among men and women worldwide. Earlier studies on the positive aspects of profanity mostly relate to pain management and the release of negative emotions. The uniqueness of the current study is its analysis for a possible constructive role of profanity in stress, anxiety, and depression.

Method

The current survey involved 253 conveniently selected participants from Pakistan. The study analyzed the role of profanity in connection to stress, anxiety, and depression. Profanity Scale and the Urdu version of Depression, Anxiety, and Stress Scale were used along with a structured interview schedule. Descriptive statistics, Pearson's correlation coefficient, and t-test were implied to obtain results.

Results

The study revealed that the usage of profane language had significantly inverse correlations with stress (r = -0.250; p < 0.01), anxiety (r = -0.161; p < 0.05), and depression (r = -0.182; p < 0.01). Higher profaners also revealed significantly lower levels of depression (M = 29.91, SD = 10.80 vs. M = 33.48, SD = 10.40; p = 0.009; Cohen's d = 0.338) and stress (M = 30.83, SD = 11.41 vs. M = 35.16, SD = 11.31; p = 0.003; Cohen's d = 0.381) as compared to lower profaners. Profanity had no significant correlations with age (r = 0.031; p > 0.05) and education (r = 0.016; p > 0.05). Men projected significantly higher levels of profanity as compared to women.

Conclusion

The current study viewed profanity similar to the self-defense mechanisms and emphasized on its cathartic role in stress, anxiety, and depression.

Defense mechanism responses to COVID-19

The COVID-19 pandemic has had a wide range of negative physical and mental impacts. This review begins with a theoretical explanation of the psychological defense mechanisms used to deal with the pandemic. It then discusses different categories of defense mechanisms and their roles in managing the impacts of psychological distress. The aim of this review is to highlight the various psychological defense mechanisms individuals use to deal with the pandemic and to discuss how adjustment mechanisms can protect individuals from internal and external threats by shielding the integrity of the ego (the mind) and helping individuals maintain their self-schema.

Insight Into Illness and Psychological Defense Attitudes in People With Chronic Schizophrenia Using Markova's Insight Scale

ABSTRACT

Insight into illness is a multidimensional phenomenon, and various assessments are available. We focused on Markova's Insight Scale (IS) and investigated the relationship between insight, psychological defenses, and neurocognition in 38 patients with schizophrenia. Results showed that insight was significantly correlated with an immature defense style. Moreover, IS was significantly predicted by immature defense style after adjusting for clinical variables. Although insight is often assumed to be multidetermined with potential contributions from factors such as cognitive function and psychological defensive mechanisms, our results indicated that better insight assessed with the IS is more likely to reflect immature defenses. This may also be reflected in our result that a higher insight score correlated with earlier onset of illness. The insight score may reflect the immature psychological defensive attitudes of schizophrenia and may lead such patients to wish to comply with the views of clinicians.

Associations Between Defence-Style, Eating Disorder Symptoms, and Quality of Life in Community Sample of Women: A Longitudinal Exploratory Study

Background and Aim: Eating Disorders (EDs) impact an estimated 15% of the global population and are linked to maladaptive defence-styles (coping strategies) and poorer mental health outcomes. Defence-styles have been grouped into immature, neurotic, and mature behaviours. Studies have yet to examine all three defence-styles in ED symptomatic individuals over an extended period of time. The current study aimed to investigate using converse analysis the relationships between defence-style and ED outcomes over a 5-years period. Methods: Participants (n = 216, mean age 33 years) were recruited through the Women's Eating and Health Literacy study, with the current study examining a 5-years period of two waves (year-4 and year-9). The current study tested associations over time between eating pathology (EDE-Q), psychological distress (K10), mental and physical health related quality of life (M/PHRQoL, SF-12), and defence-style (DSQ-40). Results: Mature, immature and neurotic defence-styles did not significantly change over 5 years. Over the same period, only PHRQoL significantly predicted mature defence-styles having positive effect. Both MHRQoL and PHRQoL significantly predicted immature defence-styles having positive and negative effects, respectively. Psychological distress, PHRQoL and weight concern significantly predicted neurotic defence-styles having positive effects except for psychological distress. PHRQoL, MHRQoL, restraint and eating concern significantly predicted overall eating pathology having positive effects except for PHRQoL and MHRQoL. Conversely, among the defence-style variables, over 5 years, both immature and neurotic defence-styles significantly predicted psychological distress having positive effects, immature and mature defence-styles significantly predicted MHRQoL having negative and positive effects, respectively, while only immature defence-styles significantly predicted overall eating pathology having positive effect. Conclusions: The results of the current study suggest that immaturity and neuroticism but not maturity were the defence-style variables predicting psychological distress over a 5-years period while conversely psychological distress predicted only neurotic defence styles. The findings of the current study may suggest that without intervention, mature, immature and neurotic defence-styles may largely remain immutable to significant shifts over time. Limitations in the current study included limited demographic representation. The current study is anticipated to generate considerations into treatments that could strengthen defence-styles in individuals with increased eating pathology.

Defense Mechanisms and Treatment Response in Depressed Inpatients

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery-Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient's defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy.

Temperament, Character, and Defense Mechanism Changes With Treatment in Depression: A 9-Month Naturalistic Follow-up

The aim of this study was to evaluate the changes in temperament, character, and defense mechanisms with the treatment and remission in patients with major depressive disorder. The study was designed as a longitudinal observational follow-up study of patients with repeated measures at 0, 12, and 36 weeks. In baseline comparisons, the major depression group showed higher harm avoidance and novelty seeking scores and lower self-directness and mature defense styles scores compared with healthy controls. In the follow-up, temperament dimensions and neurotic defenses remained unchanged, mature defense styles and self-directness revealed significant increase, and immature defense styles revealed significant decrease. Although there was no significant difference in the defense styles, harm avoidance and novelty seeking scores remained higher in MDD patients compare with healthy controls in 36 weeks. Our findings regarding continuation of hierarchically upward improvement in defense mechanism after the remission may support importance of treatment after remission.

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.

Differences in Personality, Defense Styles, and Coping Strategies in Individuals with Depressive Disorder According to Age Groups Across the Lifespan

OBJECTIVE

This study aimed to examine the differences in personality, defense style, and coping styles among patients with depression according to age groups.

METHODS

A total of 211 participants ranging from 19 to 81 years old were recruited for the study. To assess participants' five dimensions of personality, the Neuroticism-Extraversion-Openness Personality Inventory-Revised (NEO-PI-R) was administered. In addition, the Korean-Defense Style Questionnaire and the Korean version of the coping checklist were administered to examine the defense and coping style.

RESULTS

In the analysis of NEO-PI-R, the mean value of Agreeableness, Conscientiousness, and Neuroticism showed significant differences between the young adult age group (20-34 years) and the late middle age group (50-64 years) (p<0.05). The young age group used more immature defense styles and made less use of problem-focused coping strategy than the old age patients (65 years and older) (p<0.05).

CONCLUSION

In the young age group associations with lower Agreeableness and Conscientiousness, as well as higher Neuroticism than the late middle age group were observed. Moreover, the young age group had a higher usage of immature defense style, and restricted use of problem-focused coping style than other age groups.

Disentangling within- and between-patient effects of defensive functioning on psychotherapy outcome using mixed models

Abstract There is a great need to identify predictors of treatment response, and the analysis of defense mechanisms is a promising approach. Defensive functioning may influence psychotherapy outcome in two ways: First, when it is generally higher or lower for some patients relative to others and second, as it shifts in individual patients over time. The present study examined both within- and between patient effects of defenses using hierarchical linear modeling. Forty-seven patients diagnosed with depression, anxiety, or adjustment disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy in a university outpatient clinic. The Defense Mechanism Rating Scale (DMRS) was used to assess defenses in the 1st, 8th, 16th, and 24th session and relate them to symptom severity of depression and anxiety. A higher number of adaptive defense mechanisms was associated with less severe depressive symptoms during treatment while a higher number of immature defenses was related to more severe depressive and anxiety symptoms. An increase in adaptive and a decrease in immature defenses over the course of treatment predicted symptom reduction of depression whereas a decrease in neurotic and immature defenses was associated with reductions in anxiety symptoms. Our results empirically support defensive functioning as a mechanism of change in psychotherapy.

Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial

BACKGROUND

Defense mechanisms play an important role in the development and maintenance of both health and psychopathology. Research is still in the early stages of investigating the specific relationships among diagnostic groups and defense mechanisms along with their response to different treatment types.

METHODS

For the present study a total of 47 outpatients diagnosed with depression or anxiety disorders were randomized to receive 25±3 sessions of cognitive-behavioral therapy with integrated elements of either emotion-focused therapy (CBT + EFT) or treatment components based on self-regulation theory (CBT + SR). An observer-rated method, the Defense Mechanism Rating Scale (DMRS) was used to code transcripts of the 1st, 8th, 16th and 24th session to assess change in defensive functioning.

RESULTS

Over the course of therapy, overall defensive functioning (ODF) as well as adaptive defenses increased significantly, whereas maladaptive and neurotic defenses did not change. At the beginning of treatment, the proportion of adaptive defenses and ODF was significantly higher in patients diagnosed with anxiety disorders than in patients with depressive disorders. However, depressed patients exhibited greater improvement in their defensive functioning over the course of therapy.

CONCLUSIONS

Results support the view of defense mechanisms as a useful transdiagnostic and transtheoretical concept and supports the notion that change of defense mechanisms may be a relevant mechanism of change in psychotherapy.

Assessing Personality Change with Blatt's Anaclitic and Introjective Configurations and Shedler-Westen Assessment Procedure Profiles: Two Case Studies in Psychodynamic Treatment

A growing body of empirical and clinical research attests to the influence of personality features on the development, course and outcome of psychotherapy. Over the last four decades, Blatt adopted a psychoanalytic and cognitive developmental approach in developing a theoretically and empirically grounded two-configurations model of personality. The main aim of this study was to evaluate possible changes in anaclitic and introjective configurations - as measured by the Depressive Experience Questionnaire (DEQ) (Blatt, D'Afflitti, & Quinlan, 1976) - set against simultaneous changes in personality profile measured by Shedler-Westen Assessment Procedure (SWAP-200). Two young patients, a man and a woman, characterized by different personality profiles - introjective and anaclitic, respectively - were assessed for one year in the context of a psychodynamic psychotherapy. A battery of instruments - Beck Depression Inventory II (BDI-II), Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders I and II, Defense Mechanism Rating Scale, DEQ and SWAP-200 - were administered at the beginning, during the assessment process, and after one year. Both patients displayed lower BDI-II scores, along with evident clinical progress. Defence profiles and Core Conflict Relationship Themes showed interesting developments, in keeping with the evolution of the psychotherapy process. Lastly, while DEQ profiles outlined substantial stability after one year, some important changes in SWAP-200 profiles - in particular with regard to Q factors - were observed. Although these findings should be considered as preliminary, these results appear to be consistent with the description of Self-criticism and Dependency as relatively stable personality dimensions. The potential influence of profile diversity - introjective vs anaclitic - on other key variables of the psychotherapy process is also discussed.

Defense Mechanisms in "Pure" Anxiety and "Pure" Depressive Disorders

Our study was intended to test whether there are any differences in the way defense mechanisms are used by patients suffering from pure anxiety and those with pure depressive disorders. The sample size was as follows: depressive disorders without psychotic symptoms 30, anxiety disorders 30, and the healthy control group 30. The assessment of defense mechanisms was made using the DSQ-40 questionnaire. Our findings show that "pure" anxiety disorders differ from "pure" depressive disorders only in the use of immature defense mechanisms. The group with depressive disorders was significantly more prone to use immature defense mechanisms than the group with anxiety disorders (p = 0.005), primarily projection (p = 0.001) and devaluation (p = 0.003). These defense mechanisms may therefore be used both to differentiate between anxiety and depressive disorders and also to determine which symptoms (anxiety or depressive disorders) are dominant at any given stage of treatment.

Adolescent Defense Style as Correlate of Problem Behavior

Abstract. Objective: Adolescent problem behaviors are often the visible results of intrapsychic distress. Defensive reactions are the unconscious means of managing intrapsychic distress. This cross-sectional study examines the strength of defensive style as measured by self-report on the Response Evaluation Measure (REM-71) relative to age, sex, and SES, as a correlate of internalizing and externalizing problem behaviors, as assessed by the Youth Self Report (YSR). Methods: A sample of 1,487 students from two suburban high schools completed self-report measures of defense style, self-esteem, and internalizing and externalizing problem behaviors. Demographic variables (age, sex, and SES) were included as covariates. Results: Mature and immature defense style correlated as expected with problem behaviors. Demographic variables contributed minimally to the variance in the outcome variable. Conclusions: Defense style, as assessed by the REM-71, is a significant correlate of clinically elevated internalizing and externalizing problem behaviors in youth as in adults. This study adds to the convergent validity of the REM-71.

Observing the determinants of the psychotherapeutic process in depressive disorders. A clinical case study within a psychodynamic approach

This paper focuses on the relationship between depressive disorders, personality configurations, and mental functioning. A one-year treatment of a young man with the diagnosis of Depression is presented: the clinical and empirical points of view are described in depth through an assessment at the beginning and at one year after of an oriented psychodynamic psychotherapy. SCID I and II and HAMRS were administered to the patient in assessment phase. In the same phase he filled in BDI-II, and DEQ; the psychotherapist completed SWAP-200. These clinician instruments were used again after 1 year of the treatment. The PDM point of view is also presented. All sessions are audiotaped: 12 verbatim transcripts were coded with the Defense Mechanisms Rating Scale and CCRT. The results show a decrease in depressive symptoms, a change in some personality configurations, but a substantial invariance of the introjective profile, and a modification in mental functioning.

Association between defense mechanisms and psychiatric symptoms in North Korean Refugees

OBJECTIVE

Defense mechanism may contribute to psychiatric symptoms. Refugees are vulnerable to various psychiatric symptoms, such as depression, anxiety, somatization, and those associated with post-traumatic stress disorder (PTSD), due to their traumatic or stressful experiences. We aimed to investigate the mediating role of each defense mechanism in the occurrence of specific psychiatric symptoms in North Korean refugees.

METHOD

Among 213 North Korean refugees initially recruited, 201 completed the following questionnaires: the Defense Style Questionnaire, the Center for Epidemiological Studies-Depression Scale (CES-D), the State-Trait Anxiety Inventory-State (STAI-S), the somatization subscale of Symptom Check-List-90-Revised (SCL-90-R), and the Impact of Event Scale-Revised (IES-R). Stepwise regression analysis was performed to determine the defense mechanisms more predominantly associated with specific psychiatric symptoms after controlling for age, sex, number of traumatic experiences, and other psychiatric symptoms (depressive symptoms and/or anxiety).

RESULTS

Higher levels of depression were independently predicted by greater use of resignation. More use of acting out and less use of humor and sublimation independently predicted higher levels of anxiety. Somatization was independently predicted by more use of inhibition. PTSD symptoms were independently predicted by more use of undoing and isolation.

CONCLUSIONS

Specific psychiatric symptoms were associated with specific defense mechanisms in North Korean refugees. Our findings suggest that the manifest psychiatric symptoms of refugees may be mediated by their dominant defense mechanism.

Association between PPP1R1B polymorphisms and defense mechanisms in healthy Chinese-Han subjects

Defense mechanisms resulting from the interaction between biological factors and the environment have been established. In genetic studies, dopamine genes have been recognized to play an important role in the determination of defense mechanisms. DARPP-32 (dopamine- and cAMP-regulated phosphoprotein) plays a central role in the biology of dopamine-receptive neurons; its coding gene (PPP1R1B) has been linked to psychological and psychopathological traits. Here, we aimed to explore the association between PPP1R1B polymorphisms and defense mechanisms measured using the 88-item Defense Style Questionnaire in 400 healthy Chinese-Han subjects. Of the three polymorphisms examined, rs12601930 was associated with projection (P = 0.028) and splitting (P = 0.032), while rs3764352 was associated with splitting (P = 0.042). No significant association was found between rs879606 and defenses. When analyzed separately by gender, no significant association between defense mechanisms and PPP1R1B polymorphisms in males was observed. In females, however, rs12601930 was significantly associated with splitting (P = 0.018), and rs879606, with projection (P = 0.015), help-rejecting complaining (P = 0.030), and immature defense style (P = 0.031), while rs3764352 was not associated with any defense. The distribution of genotypes between the low- and high-scoring subgroups for each defense style showed no significant differences. Our results suggest that PPP1R1B polymorphisms are, at least partially, responsible for immature defenses.

Defense style in panic disorder before and after pharmacological treatment

Whether or not the use of maladaptive defense style is a trait, as opposed to a state dependent phenomenon, in panic disorder (PD) is a topic still very much up for debate. The aim of the study was to verify whether PD patients, both before and after treatment, used different defense style than the control group. Sixty-one PD patients (recruited from an original sample of 90 patients) and 64 healthy controls were evaluated against the Structured Clinical Interview for DSM-IV disorders, the Symptoms Check List-90, the Hamilton Rating Scales for Anxiety and for Depression and finally the Defense Style Questionnaire-40 (DSQ). The patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission. The DSQ was re-administered to the patients at the end of the study. Before treatment, PD patients used more neurotic and immature forms of defense than controls. After treatment, those in remission used the same defense styles as the control group, whereas non-remitters still used more immature defenses. However, all the aforementioned difference disappeared, after excluding the effect of symptom severity. Our data supports the hypothesis that the use of maladaptive defenses might be the consequence of PD: when subjects fall ill, their capacity to use mature adaptive defenses may diminish, but when they recover their defensive style returns to a greater maturity. The present results are however limited by the dropout rate (one third of patients did not complete the study) and the use of just one questionnaire to evaluate the complexity of defense styles.

Defensive flexibility and its relation to symptom severity, depression, and anxiety

Numerous studies have examined which individual defense mechanisms are related with mental health, and which are linked with psychopathology. However, the idea that a flexible use of defensive mechanisms is related to psychological wellbeing remained a clinical assumption, which this study sought to test empirically. A total of 62 (N = 62) outpatients participated in the study and were assessed with the Symptom Checklist-90R and the Social Adjustment Self-rated Scale. A subsample of 40 participants was further assessed using the Hamilton Depression (HAMD-21) and Anxiety scales (HAMA-21). The first therapy session of all participants was transcribed and rated using the Defense Mechanisms Ratings Scales (), and the Overall Defensive Functioning (ODF) score, which indicates the maturity of one's defensive functioning, was computed. An indicator of flexible use of defenses was also calculated based on the Gini Concentration C measure. Results showed that defensive flexibility, but not ODF, could predict anxiety scores. Symptom severity was predicted by both ODF and defensive flexibility, although in directions opposite to our predictions. Results suggest that defensive flexibility captures another aspect of an individual's functioning not assessed by the ODF, and that it is a promising new way of documenting defensive functioning.

Mixed anxiety and depressive disorder before and after psychodynamic group psychotherapy: a 1-year follow-up study

Abstract Objective. The aim of our study was to observe the outcome of MADD in comparison with depressive (DD) and anxiety (AD) disorders. Method. Patients treated with 12 weeks of group psychodynamic psychotherapy in a psychiatric day care ward were examined using SCAN 2.1 at admission and 1 year after admission. Treatment was indicated on the basis of diagnosis of ICD-10 - F4-F6. A total of 139 patients were included, 110 (79.1%) of whom were examined at the follow-up point. Results. The prevalence of MADD increased from 22.7% at the baseline to 33.6% at the end. The outcome of MADD was statistically different from the outcome of DD (χ(2)=18.4, P=0.0025), but not different from the outcome of comorbid DD and AD (χ(2)=1.8, P=0.84), nor generalized anxiety disorder (χ(2)=8.1, P=0.15), nor other AD (χ(2)=5.3, P=0.38). Conclusion. MADD is a useful diagnosis of a transitional or residual form of comorbid DD and AD in some specific population groups. A diagnosis of personality disorder can sustain long-term diagnosis of MADD.

The use of the defence style questionnaire in major depressive and panic disorders: a comprehensive meta-analysis

PURPOSE

The issue of defence mechanisms is of great importance in clinical practice. The aim of this meta-analysis is to compare different defence styles (Mature, Neurotic, and Immature), assessed using the three-factor defence style questionnaire (DSQ), in major depressive disorder (MDD), and panic disorder (PD) in order to evaluate potential differences in defence profiles among these disorders.

METHODS

We assessed all publications listed in PubMed, PsycINFO, ISI, and Lilacs databases focusing on DSQ defence styles in MDD and PD. To be included studies had to be published in English, to include psychiatric patients, to provide defence style mean scores, and to employ the three-factor DSQ versions. Data were entered into the Cochrane Collaboration Review Manager Software and analysed by RevMan version 4.2.

RESULTS

MDD patients reported significantly lower scores in Mature style and both MDD and PD patients reported significantly higher scores in Neurotic and Immature styles.

CONCLUSIONS

A dissimilarity between depressive and anxious profiles emerged, since the former profile was characterized by low Mature and high Neurotic and Immature scores while the latter by high Neurotic and Immature scores only. These results could indicate the use of specific strategies in clinical and psychotherapeutic management of patients with these diagnoses. Nevertheless, present results should be considered with caution because of the high heterogeneity of the studies and some weaknesses in the psychometric properties of the DSQ.

Does defense style or psychological mindedness predict treatement response in major depression?

BACKGROUND

The aim of this study was to define the impact of defense style and psychological mindedness (PM) on the prognosis of major depressive disorder (MDD) in patients treated with either fluoxetine (FLX) or short-term psychodynamic psychotherapy (STPP) in a randomized comparative study.

METHOD

50 patients with MDD received either STPP or FLX treatment for 16 weeks. The Hamilton Depression Rating Scale (HDRS) was the outcome measure completed at baseline and in the follow-ups at 4- and 12-months. Patients completed the Psychological Mindedness Scale (PMS) and the Defense Style Questionnaire at the baseline.

RESULTS

In the FLX group recovery measured by the decrease in the HDRS during the 4-month follow-up associated with baseline mature defense style (r=-.59, P=.015). There were no correlations between the PMS-scores and the outcome measures in either treatment groups nor defense status and the outcome in the STPP group.

CONCLUSION

Mature defense style predicts good response to FLX therapy in major depression. This association was not found in the psychotherapy group. The results may imply that patients with immature defenses benefit relatively more from brief psychotherapy than medication. PM measured by the PMS was not useful in predicting recovery in MDD.

Defense style changes with the addition of psychodynamic group therapy to clonazepam in social anxiety disorder

Psychodynamic Group Therapy (PGT) and clonazepam are strategies to reduce symptoms of generalized social anxiety disorder (GSAD). The addition of PGT might lead to changes in defense styles. The objective of this study is to examine changes in defense styles when comparing clonazepam to psychodynamic group therapy plus clonazepam in GSAD during 12 weeks. Fifty-seven patients that met DSM-IV criteria for GSAD participated. social anxiety disorder symptoms were evaluated with the Liebowitz Social Anxiety Scale, and defense styles with the Defense Style Questionnaire. All defense styles changed overtime for both groups, especially mature defense style, which increased independently of the treatment allocation group. Regression analyses found that overtime there was a reduction in neurotic defenses in the combined group, whereas there was an increase in the clonazepam group. Neurotic defense style can change toward greater adaptiveness with the addition of PGT to clonazepam in GSAD, even in 12 weeks.

Defense mechanisms and suicide risk in major depression

Past suicide attempt has been consistently reported to be the best predictor of future suicide attempt. The need to identify predictors that can be targets of therapy is of great importance. Coping styles and defense mechanisms have now been linked to suicide in numerous reports. In this study, we expand on past research by exploring differences in defense mechanism use between three groups: 1) without current suicide ideation/attempt; 2) with current suicide ideation/no attempt; and 3) with current suicide attempt. We also explored the contribution of covariates, such as symptom severity and past attempt. Seventy-five adult patients who were within 48 hours of hospital admission for current major depressive episode were recruited. Clinical interview was conducted to verify diagnosis and assess symptom severity. Patients completed the Defense Style Questionnaire within 48 hours of admission based on their current thoughts and beliefs. Logistic regressions were used to determine the best predictors of current suicide status. Consistently, the use of more image-distorting mechanisms was the best predictor of current suicide attempt. Symptom severity and past attempt were not significant predictors after controlling for influence of defense styles. Decreased use of image-distorting mechanisms in adult patients with major depressive disorder should be considered as a distinct target of therapy.

Do defense mechanisms vary according to the psychiatric disorder?

OBJECTIVE

The aim of this study was to evaluate the defense mechanisms used by depressive and anxious patients without comorbidities compared to those used by controls and to determine whether these patterns differ between diagnoses.

METHOD

The sample was composed of 167 psychiatric patients and 36 controls that were evaluated using the Defense Style Questionnaire 40. All subjects were evaluated through a clinical interview, and each evaluation was confirmed through the application of the Mini International Neuropsychiatric Interview, a structured psychiatric interview. We used ANOVA and discriminant analysis to assess differences between groups.

RESULTS

Neurotic defense mechanisms discriminated controls from all patients except those with social anxiety. Immature defense mechanisms differentiated controls from all patients, as well as distinguished depressive patients from panic disorder and obsessive disorder patients. The discriminant analysis indicated that depressive patients are characterized by projection, panic disorder patients by sublimation and obsessive-compulsive patients by acting out.

CONCLUSIONS

Depressive and anxious patients differ from other individuals in their use of defense mechanisms, and each diagnosis has a particular pattern. These findings could lead to the development of specific psychotherapeutic interventions.

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.

How psychiatric treatments can enhance psychological defense mechanisms

Psychological defense mechanisms are a powerful and often unappreciated force safeguarding mental health. Although rarely directed in this way, the most common forms of psychiatric treatment-psychotherapy and antidepressants-can enhance psychological defense mechanisms. Psychotherapy, through both specific and nonspecific factors, induces positive perspective shifts favoring positive cognitive distortions, including adaptive classical defense mechanisms and healthy attribution biases. Antidepressants, by altering very basic emotional information processing, such as facial expression recognition and emotional memories, also foster positive cognitive distortions. By shifting perceptions and thoughts in a positive direction, psychotherapy and antidepressants improve the capacity to dissociate from negative emotional stimuli.

Psychological defense styles, childhood adversities and psychopathology in adulthood

OBJECTIVE

The present study explores the link between reported sexual and/or physical abuse and psychological defense styles, as well as the association of both with psychological distress in adulthood. In two patient samples that differ in psychological distress and somatization, we examine whether the adversities reported and immature defense styles are associated with psychopathological symptoms.

METHOD

We examined 266 consecutive inpatients in the psychosomatic department and 109 consecutive inpatients who had been treated for low-back pain in the orthopedic department of a German university hospital. Psychological defense styles were assessed by a two-factor solution of the German modified adaptation of the Defense Mechanism Inventory (DMI), childhood adversities by a structured interview, psychological distress by the SCL-90-R, and somatization by the Screening for Somatoform Disorders (SOMS).

RESULTS

Both samples demonstrated a significant link between immature defense styles and the extent of overall psychological distress as well as somatization. Reported sexual and/or physical abuse of patients in both patient samples was directly associated with somatization.

CONCLUSION

Recollections of sexual and/or physical abuse in childhood and immature defense styles have an association with psychopathology in adulthood. This finding suggests that immature defense styles may act, in part, as mediators between the adversities investigated and adult psychopathology.

[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.

Perfectionism, Ego Defense Styles, and Depression: A Comparison of Self-Reports Versus Informant Ratings

The present study examined the associations among perfectionism, defense styles, and depression in an Israeli community sample of young adults. This study involved a comparison of self-reports and informant ratings on all measures. A community sample of 210 pairs of same-sex best friends from Israel completed the Multidimensional Perfectionism Scale, the Defense Styles Questionnaire - 40, and a depression measure. Analyses confirmed that socially prescribed perfectionism is associated with depression, not only in terms of self-reports but also in terms of informant ratings. In addition, informant ratings revealed a link between other-oriented perfectionism and depression. Both self-reports and informant ratings also indicated that socially prescribed perfectionism is associated with immature defense styles and neurotic defense styles. Further simultaneous Structural Equation Modeling (SEM) analyses of self-reports and informant ratings showed that maladaptive defense styles mediate the link between socially prescribed perfectionism and depression. The practical and theoretical implications of these findings are discussed.

Evaluation of defense mechanisms in adult patients with panic disorder: before and after treatment

Patients with acute panic disorder (PD) use a more maladaptive pattern of defense mechanisms. This study investigated the use of defense mechanisms by patients with acute symptomatic PD and those in complete remission. Thirty-three patients and 33 controls were evaluated by the Mini International Neuropsychiatric Interview. The defense mechanisms were evaluated by the Defense Style Questionnaire at the beginning of the study and after 16 weeks of sertraline treatment. Panic disordered patients used more neurotic (4.6 vs. 3.6; p = 0.003) and immature (3.6 vs. 3.0; p = 0.024) defenses at baseline. Patients who achieved complete remission (N=25) differed from the control group in the use of neurotic defenses at the baseline (4.4 vs. 3.6; p = 0.033). After treatment, they showed a reduction in the use of neurotic (4.4 vs. 3.7; p=0.014) and immature (3.4 vs. 3.1; p = 0.019) defenses. Defense mechanisms in PD are influenced by the presence of symptoms, severity, and outcome of the disease.

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.

Reports on defense styles in depression

INTRODUCTION

'State effect' of depression on personality makes its assessment during depression difficult. Many clinicians do not only refer to the patient, but use additional information sources, especially reports from close informants. Our hypothesis was that an informant could assess the defensive functioning of the depressed patient. The objective of this study was to investigate the validity of the informants' assessment of defense styles in depressed patients.

METHODS

Sixty-three inpatients with DSM-IV major depression as primary diagnosis were included. They were administered the Defense Style Questionnaire (DSQ) at admission (D0) and 28 days after treatment (D28) according to their current state. At the same time, informants rated an adapted version of the DSQ (INF-DSQ), according to the patient's current (D0 and D28) and premorbid defensive functioning (D0). Otherwise, severity of depression was assessed using the 17-item Hamilton Depression Rating Scale at D0 and D28.

RESULTS

Agreement between patient's and informant's DSQ scores was moderate, both at D0 and D28, even if comparison of mean defense scores does not show significant difference. Mature defense scores significantly increased between D0 and D28, whereas immature defense scores significantly decreased, with both the DSQ and INF-DSQ. During the episode, informants are able to discriminate premorbid from current D0 defenses, but not from current D28 defenses.

CONCLUSION

Even if this study has strong limitations, our results argue for the interest of close informants to assess premorbid personality. Before it could be validated, the INF-DSQ should be further studied in other subgroups of patients, especially its ability to give accurate descriptions of patient's premorbid defenses during an acute episode.

Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insecure attachment style

BACKGROUND

This study prospectively investigated the factors underlying the maintenance and persistence of postnatal depression beyond the first year after birth.

METHOD

One hundred primiparous women who were admitted to a parentcraft hospital for a week were assessed after discharge at 4 and 12 months postpartum. Various measures of mood, interpersonal relationships and defence styles were administered at 4 months and the relation between these measures and clinically elevated symptoms of depression at 12 months was examined.

RESULTS

At 12 months, 30% of all mothers and 60% of those diagnosed depressed at 4 months continued to report clinically significant levels of depressive symptomatology. The strongest predictor of depression at 12 months was severity of symptoms at 4 months, and women from a non-English speaking background were significantly more likely to remain depressed. Reports of low maternal care in childhood, marital dissatisfaction at 4 months, an attachment style characterised by anxiety over relationships and immature defence styles were significant predictors of clinically elevated depression scale scores at 12 months. Furthermore, an insecure attachment style was shown to mediate the effect of low maternal care in childhood, while other cognitive and interpersonal factors appeared to contribute additively in maintaining depressive symptoms.

LIMITATIONS

Self-report measures were used to measure insecure attachment styles and depression at 12 months.

CONCLUSIONS

Findings demonstrate that both childhood and concurrent relationship difficulties contribute to the maintenance of postpartum depression. Interventions for persistent depression need to address relationship difficulties as well as depressive symptomatology.

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.

Brazilian patients with panic disorder: the use of defense mechanisms and their association with severity

This study aims to evaluate the defense mechanisms most frequently used by Brazilian patients with panic disorder when compared with a control group. The study also examines the association between severity of disease and comorbidity and the use of specific defense mechanisms. Sixty panic-disordered patients and 31 controls participated in the study. The Mini International Neuropsychiatric Interview was used to confirm the panic disorder diagnosis and to establish the comorbid diagnosis. The Clinical Global Impression (CGI) was used to assess severity and the Defensive Style Questionnaire (DSQ-40) was used to evaluate the defense mechanisms. Panic patients used more neurotic (mean = 4.9 versus 3.6; p < 0.001) and immature (mean = 3.9 versus 2.8; p < 0.001) defenses as compared with controls. Panic patients with severe disease (n = 37; CGI>4) had more depression comorbidity and used more immature defenses than patients with CGI<or=4 (n = 23; mean = 4.2 versus 3.5; p < 0.001). It was concluded that the panic severity and depression comorbidity found in Brazilian panic-disordered patients are associated with the use of maladaptive mechanisms, namely immature defenses.

The use of defenses and physician health care costs: are physician health care costs lower in persons with more adaptive defense profiles?

BACKGROUND

The objective of the present study was to determine if persons who use more adaptive defenses have lower physician health care costs compared to those who use less adaptive defenses.

METHODS

We randomly selected 667 persons from the 1995 population-based Nova Scotia Health Survey who completed a videotaped structured interview. Each interview was rated for typical defense use by the Defense-Q. We obtained physician health care costs for 3 months before and after the interview, as well as medical diagnoses and measures of psychological functioning.

RESULTS

A more adaptive defense profile significantly predicted lower future physician health care costs. These results were found when controlling for other psychosocial variables, before and after controlling for previous physician health care costs, and when testing only within a physically healthy subsample. Results of secondary analyses showed that a more adaptive defense profile was positively related to a number of psychosocial variables, such as nurse's rating of competence, lack of depressive symptoms, and days at work.

CONCLUSIONS

The adaptiveness of a person's defense use in managing affect is important in predicting physician health care costs as well as psychosocial functioning.

Defense styles explain psychiatric symptoms: an empirical study

To examine the relation between psychiatric symptoms and defense mechanisms, we administered two questionnaires, the Symptom Check-list 90 (SCL-90) and the Defense Style Questionnaire (DSQ) to 122 psychiatric out-patients and to a community sample of 337 subjects. Using regression analysis, we found that 51.8% of the variation in subject's Global Severity Index value could be explained by his defense style. Of the three defense styles, the immature style explained most of the variation in the symptoms. We found little overall evidence for specific connections between particular defenses and symptoms. Projection and dissociation were central in most of the symptom dimensions. We compared patients and controls with the same level of general symptom severity and found that patients used significantly more devaluation and splitting, and controls used significantly more altruism and idealization. Whether defenses predispose to certain symptomatology or are one of its aspects is discussed.