various Defence mechanism in psychiatry and its association in various psychiatric illness

1. DEFENSE MECHANISM
PRESENTED BY:
DR.SABAHUDDIN AMMAR
MODERATOR:
DR.DEOSHREE AKHOURI

2. SCHEME OF PRESENTATION
• Objective of presentation
• History
• Basic concepts
• Important properties
• Definition
• Role of defense mechanisms
• Classification
• Measurement
• Defense mechanisms and Psychiatric disorder

3. OBJECTIVE OF PRESENTATION
•
• Identification and notation of defense mechanisms can be an important part of
the psychological assessment and influence on the treatment process.
• Familiarisation with benefits and harms of defense mechanism.

4. HISTORY
• The concept of defense first appeared in Sigmund Freud’s article "The Neuro-
Psychoses of defense" (1894) and was next discussed in"Further Remarks on
the Neuro-Psychoses of defense" (1896) and "The Aetiology of Hysteria"
(1896).
• For Freud, the concept of defense refers to the ego's attempts at psychic
transformation in response to representations and affects that are painful,
intolerable, or unacceptable.
• He abandoned the concept of defense for a period in favor of the concept of
repression. He then reintroduced it in "Neurotic Mechanisms in Jealousy,
Paranoia and Homosexuality" (1922).

5. HISTORY(CONTD.)
• In an appendix to Inhibitions, Symptoms, and Anxiety (1926), Freud reverted to the
old concept of defense. He also retained the word “repression” for special method of
defense.
• Freud's list of basic Defense Mechanisms includes: Denial, Displacement,
Intellectualization, Projection, Rationalization, Reaction formation,Regression,
Repression and Sublimition.
• The first comprehensive study of defense mechanisms was reported by Anna Freud in
her landmark work, The Ego and the Mechanisms of defense (1937).

6. THE TRIPARTITE MODEL
OF THE MIND
• Freud
• Ego
• ID
• Superego
• The id is need gratifying and impulsive,instinctual
• Hedonic drives for instance
• Superego is roughly equivalent to conscience
• Determines that some needs are not consistent with
an underlying view of one’s self (Ego ideal)

7. EGO
• Ego is the mediator between the unconscious world of the Id and Superego and
the conscious world of reality
• The ego’s job is to mediate the struggle between the superego and id
• When superego and id are in conflict the person experiences‘signal anxiety’
• Ego must convert the signal anxiety to defuse it and make it less threatening.

8. EGO DEFENSES
• If the signal anxiety cannot be defused it may overwhelm the ego and allow the
primitive primary process thinking of the unconscious to become manifested in
the conscious life of the person.

9. BASIC CONCEPT –TYPES OF ANXIETY
• Reality Anxiety: most basic form of anxiety ,typically based on fears of real and
possible events, such as being bitten by a dog or falling from a ladder.
• Neurotic Anxiety: comes from an unconscious fear that the basic impulses of the
ID will take control of the person, leading to eventual punishment.
• Moral Anxiety: form of anxiety comes from a fear of violating values and moral
codes, and appears as feelings of guilt or shame.

10. BASIC CONCEPT
•
• According to Freud, anxiety is an unpleasant inner state that people seek to avoid.
• When anxiety occurs, the mind first responds by an increase in problem solving
thinking, seeking rational ways of escaping the situation.
• If this is not fruitful (and maybe anyway), ego has some tools it can use in its job as the
mediator, tools that help defend the ego, these are called Ego Defense Mechanisms or
Defenses.
• They helped shield the ego from the conflicts created by the id, superego,and reality.

11. IMPORTANT PROPERTIES
• Freud discovered most of the defense mechanisms and identified five of their important
properties:
1. Defenses are a major means of managing instinct and affect.
2. They are unconscious.
3. They are discrete (from one another).
4. Although often the hallmarks of major psychiatric syndromes,defenses tend to distort,
transform, or otherwise falsify reality.
5. They can be adaptive as well as pathological.

12. DEFINITION
• In Freudian psychoanalytic theory, defense mechanisms are unconscious psychological
strategies brought into play by various entities to cope with reality and to maintain self-
image.
• According to American Psychiatric Association (1994), “defense mechanisms are
patterns of feelings, thoughts, or behaviors that are relatively involuntary. They arise in
response to perceptions of psychic danger or conflict, to unexpected change in the internal
or external environment, or in response to cognitive dissonance.”

13. WHAT IS THE ROLE OF DEFENSE
MECHANISMS?
• Allow individuals a period of respite to master changes in self-image that cannot be
immediately integrated, as might result from puberty, an amputation, or a promotion (i.e.,
changes in reality).
• Deflect or deny sudden increases in biological drives. Awareness of instinctual wishes is
usually diminished; alternatively, antithetical wishes may be passionately adhered to.
• Enable individuals to mitigate unresolved conflicts with important people,living or dead.
• Keep anxiety, shame, and guilt within bearable limits during sudden conflicts with
conscience and culture.

14. CLASSIFICATION OF DEFENSE
MECHANISMS
• The list of defense mechanisms is huge and there is no theoretical consensus on the
number of defense mechanisms.
• Classifying defense mechanisms according to some of their properties(i.e. underlying
mechanisms, similarities or connections with personality)has been attempted.
• Defenses employed by ego can be listed according to variety of classification:-
Developmental Stages by Freud
Valliant (1971)
American Psychiatric Association (1994)

15. FREUD PSYCHOSEXUAL STAGES
AND DEFENCE MECHANISM
Normally there is an orderly sequence as the child
matures.
Oral (0-18 months) –narcissistic defenses (Projection,
denial, distortion)
Anal (18months-3 years) –Identification,undoing,
reaction formation, isolation,regression
Phallic / oedipal (3- 6 years) –Intellectualization
Latency (6 years to puberty) -Symbolization,
sublimation

16. ORDERLY SEQUENCE OF DEVELOPMENT
• If significant trauma occurs the child may have difficulty learning the mechanisms that
are normally learned at these times.
• Fixated – uneven development of ego function which results in a part of the ego retaining
more primitive or immature function
• Repetition compulsion – replay of events related to significant traumas

17. DEVELOPMENTAL ASPECTS
• The Id is the earliest component of the psychodynamic apparatus
• The infant is basically in a pleasure seeking mode of operating(sometimes this is confused
with ‘sexuality’)
• The infant also conceives of the world in a narcissistic fashion. Things exist only as they
relate to him or her
• At times the pleasure seeking runs into barriers in the outside world
• This result in infants being confronted with reality
• New skills and coping mechanisms develop

18. VAILLANT’S CLASSIFICATION
Narcissistic Immature Neurotic Mature
Denial Acting out Displacement Altruism
Projection Regression Dissociation Humour
Distortion Passive-aggressive
Behaviour
Reaction
Formation
Sublimation
Splitting Schizioid Fanatasy Repression Anticipation
Somatization Isolation Suppression
Introjection Rationalization Ascetiscism
Hypochondriosis Sexualization
Blocking Intellectualization

19. VAILLANT’S CLASSIFICATION(CONTD.)
Level I - Pathological Defenses
• The mechanisms on this level, when predominating, almost always are severely
pathological. These defenses, in conjunction, permit one to effectively rearrange external
experiences to eliminate the need to cope with reality.
• The pathological users of these mechanisms frequently appear irrational or insane to
others. These are the "psychotic"defenses, common in overt psychosis. However, they
are found in dreams and throughout childhood as well.
• e.g. psychotic denial, distortion.

20. VAILLANT’S CLASSIFICATION(CONTD.)
Level II - immature defenses
• These mechanisms are often present in adults and more commonly present in
adolescents.
• Lessen distress and anxiety provoked by threatening people or by uncomfortable reality.
• People who excessively use such defenses are seen as socially undesirable in that they
are immature, difficult to deal with and seriously out of touch with reality.
• Overuse almost always leads to serious problems in a person's ability to cope effectively.
• These defenses are often seen in severe depression and personality disorders.(e.g.
fantasy, projection, passive aggression, acting out,dissociation)

21. VAILLANT’S CLASSIFICATION(CONTD.)
Level III - Neurotic defenses
• These mechanisms are considered neurotic, but fairly common in adults.
• Have short-term advantages in coping, but can often cause long-term problems in
relationships, work and in enjoying life when used as one’s primary style of coping with
the world.(e.g. intellectualization, reaction formation, somatization,
displacement,repression)

22. VAILLANT’S CLASSIFICATION(CONTD.)
Level IV - Mature defenses:
• Commonly found among emotionally healthy adults & are considered mature, even
though many have their origins in an immature stage of development.
• They have been adapted through the years in order to optimize success in life and
relationships. The use of these defenses enhances pleasure and feelings of control.
• These defenses help us integrate conflicting emotions and thoughts, while still remaining
effective. Those who use these mechanisms are usually considered virtuous.
• e.g. humor, sublimation, suppression, altruism, anticipation.

23. AMERICAN PSYCHIATRIC ASSOCIATION
(1994)
Defensive deregulation : failure of defensive regulation-leading to pronounced break with objective reality
• delusional projection
• psychotic denial
• psychotic distortion
Action : deals with stressors by action or withdrawal
• acting out
• passive aggression
• help-rejecting complaining
Major image-distorting : gross distortion of image of self or others
• autistic fantasy
• splitting

24. AMERICAN PSYCHIATRIC ASSOCIATION
(CONTD.)
Disavowal : keeping stressors out of awareness with or without a misattribution of these
to external cause
• denial
• projection
• rationalization
Minor image-distorting : distortions in the image of the self or others
• devaluation
• idealization
• omnipotence

25. AMERICAN PSYCHIATRIC ASSOCIATION
(CONTD.)
Mental inhibitions: keeps potentially threatening ideas or feelings out of awareness
• Displacement
• reaction formation
• repression
• undoing
High-adaptive: optimal adaptation in handling stressors
• anticipation
• altruism
• humor
• sublimation
• suppression

26. RESULTS OF MATURE DEFENSES
1) Excellent adjustment as an adult,
2) Happiness,
3) Job satisfaction,
4) Rich friendships,
5) Fewer medical hospitalizations over life,
6) Better overall health,
7) A lower incidence of mental illness.

27. RESULTS OF IMMATURE DEFENSES
1) Poor adjustment as an adult,
2) Higher divorce rates and marital discord
3) Poor friendship patterns,
4) Higher incidence of mental illness,
5) Greater number of sick leave days taken,
6) Poorer health generally

28. NARCISSISTIC DEFENCE
MECHANISM

29. DENIAL
• Denial is simply refusing to acknowledge that an event
has occurred.
• Denial is one of Freud's original defense mechanisms. It
is considered one of the most primitive of the defense
mechanisms because it is characteristic of early
childhood development. It is a form of repression, where
stressful thoughts are banned from memory.
• Many people use denial in their everyday lives to avoid
dealing with painful feelings or areas of their life they
don’t wish to admit.
• Example: 1) Patient denies that his physician's diagnosis
of cancer is correct and seeks a second opinion.2)
Alcoholics vigorously deny that they have a problem.

30. PROJECTION
• When a person has uncomfortable thoughts or feelings, they may project these onto
other people, assigning the thoughts or feelings that they need to repress to a convenient
alternative target.
• Normally used at time of stress.
• More a person relies on it more distorted will be his perception of the external world.
• It turns neurotic or moral anxiety into reality anxiety, which is easier to deal with.
• Beyond a certain point – paranoid delusion.

31. PROJECTION
What you do:
Attribute your own undesirable impulses, feeling,
or desires to another person
Examples:
“I hate her” really means “I think she hates me”

32. DISTORTION
• “Reshaping external reality to satisfy inner need” (including unrealistic
megalomania beliefs, hallucinations, wishfulfilling delusions)
• Seen in childhood fantasies and wish full filling dreams.
• Denial denies the existence of reality while distortion distorts external reality.

33. SPLITTING
• A primitive defense. Negative and positive impulses are split
off and not integrated.
• Fundamental example: An individual views other people as
either innately good or innately evil, rather than as an
individual who is defined by his or her action.
• It can even be splitting of the ego when the patient is
existentially insecure.

34. IMMATURE DEFENCE MECHANISM

35. ACTING OUT
• Performing an extreme behavior in order to express
thoughts or feelings the person feels incapable of
otherwise expressing. e.g. Instead of saying, “I’m angry
with you,” a person who acts out may instead throw a
book at the person, or punch a hole through a wall.
• When a person acts out, it can act as a pressure release,
and often helps the individual feel calmer and peaceful
once again.For instance, a child’s temper tantrum is a
form of acting out when he or she doesn’t get his or her
way with a parent.
• Self-injury may also be a form of acting-out, expressing
in physical pain what one cannot stand to feel
emotionally.

36. REGRESSION
• Regression involves taking the position of a child in some problematic situation, rather
than acting in a more adult way.(Return to earlier and more comfortable developmental
level)
• This is usually in response to stressful situations, with greater levels of stress potentially
leading to more overt regressive acts.
• Can be simple and harmless, such as a person who is sucking a pen (as a Freudian
regression to oral fixation).
• May be more dysfunctional, such as crying or using petulant arguments.

37. Problems:
• Does not solve the problem
• People think you are immature
• You are not learning to cope well

38. PASSIVE AGGRESSION
• Unconscious expression of aggression towards others expressed indirectly,
through passivity,masochism, and turning against the self.
• Converts anger at others into procrastination,silly,provocative behavior or failure
that bothers other more than the individual.

39. FANTASY
What is done:
• Dreaming, imagining instead of living in the present world,
because you don’t feel competent to achieve.
• Pretending
Examples:
• Wanting to look good and pretending to yourself that you
are one of the movie stars you read about.
• Making up stories about how successful you are,rather than
working on your success.
Problems:
• You get stuck in the fantasy rather than using your talents
to become successful.

40. SOMATIZATION
• The transformation of negative feelings towards others into negative feelings
toward self, pain, illness, and anxiety.
• Convrting psychic derivatives into bodily symptoms and tending to react with
somatic manifestation rather than with psychic manifestation.

41. HYPOCHONDRIASIS
Exaggerating and overemphasizing an illness for the purpose of evasion and regression. In
hypochondriasis, responsibility can be avoided, guilt can be circumvented , and instinctual
impulses are warded off. Because hypochondriacial impulse are ego-alien, the afflicated
person experiences dysphoria and a sense of affliction.

42. NEUROTIC DEFENCE MECHANISM

43. DISPLACEMENT
• Displacement is the shifting of actions from a desired target to a substitute target when
there is some reason why the first target is not permitted or not available.
• Where possible the second target will resemble the original target in some way.
• It occurs when the Id wants to do something of which the Super ego does not permit.
The Ego thus finds some other way of releasing the psychic energy of the Id.
• Thus there is a transfer of energy from a repressed object to a more acceptable object.

44. DISPLACEMENT
• Displacements are often quite satisfactory and workable mechanisms for releasing energy
more safely.
• Examples A man wins the lottery. He turns to the person next to him and gives the person
a big hug.

45. DISSOCIATION
Dissociation is when a person loses track of time and/or
person, and instead finds another representation of their self
in order to continue in the moment.
• People who have a history of any kind of childhood abuse
often suffer from some form of dissociation.
• In extreme cases, dissociation can lead to a person
believing they have multiple selves (“multiple personality
disorder”).
• People who use dissociation often have a disconnected
view of themselves in their world.Time and their own self-
image may not flow continuously, as it does for most people.

46. REACTION FORMATION
• Reaction Formation occurs when a person feels an urge to do or
say something and then actually does or says something that is
effectively the opposite of what they really want. It also
appears as a defense against a feared social punishment.
• A common pattern in Reaction Formation is for the person to
show ‘excessive behavior’.
What you do:
• In defense against the threatening impulse, express the opposite
impulse.
• Psychoanalysts believe that extreme patterns of Reaction
Formation are found in paranoia and obsessive-compulsive
disorder (OCD),where the person becomes trapped in a cycle of
repeating a behavior that they know (at least at a deep level) is
somehow wrong.

47. REACTION-FORMATION
Examples:
• A person who is angry with a colleague actually
ends up being particularly courteous and friendly
towards them.
• Someone frightens you so you act super nice.
•A student who cheats on a test may say″I only
cheated on a few questions.I knew most of the
answers!‶
• The sex offender becomes the great protector of
society.

48. REPRESSION
• Repression involves placing uncomfortable thoughts in
relatively inaccessible areas of the subconscious mind.
• Thus when things occur that we are unable to cope with
now, we push them away, either planning to deal with
them at another time or hoping that they will fade away
on their own accord.
• The level of 'forgetting' in repression can vary from a
temporary abolition of uncomfortable thoughts to a high
level of amnesia, where events that caused the anxiety are
buried very deep.
• A high level of repression can cause a high level of
anxiety or dysfunction, although this may also be caused
by the repression of one particularly traumatic incident.

49. REPRESSION
• Repression is not all bad. If all uncomfortable memories
were easily brought to mind we would be faced with a
non-stop pain of reliving them.
• e.g. A child who is abused by a parent later has no
recollection of the events, but has trouble forming
relationships.
• A man has a phobia of snakes but cannot remember the
first time he was afraid of them.
• In normal individual during childhood,whole of the
oedipal complex is repressed.
Problems:
• Depletes energy
• Blocks out stressful situations that could be worked out

50. ISOLATION
• Separation of idea from its appropriate affect.
• The idea deprived of its affective tone enters conscious awareness , but the affect
is repressed.
• Protective due to the repression of the affect.
• The idea itself may be tormenting, guilt producing,but the discomfort is not as
that if the affect is suddenly made conscious.
• Seen in obsessional thinking.

51. RATIONALIZATION
• When something happens that we find difficult
to accept, then we will make up a logical reason
why it has happened.
• When a person does something of which the
moral super ego disapproves, then the ego seeks
to defend itself by adding reasons that make the
action acceptable to the super ego.
• Thus we are able to do something that is outside
our values and get away with it without feeling
too guilty.

52. RATIONALIZATION
What you do:
• Make up excuses for inadequacies, failure,or loss
Examples:
• A parent punishes a child and says that it is for the child's 'own
good'.
• A person evades paying taxes and then rationalizes it by talking
about how the government wastes money (and how it is better for
people to keep what they can).
• If I had better teachers, I would have gotten higher grades.

53. INTELLECTUALIZATION
• Dealing with emotional stressors by excessive use of
abstract thinking or complex explanations to control or
minimize disturbed feelings.
• Reacting in a cold way focusing on the intellectual aspect
only.
• Example :
• A husband constructing elaborate logical explanation
for wife’s recent paranoid ideas.
• A person who has been diaganosed as a case of
terminal medical illness,instead of expressing their
sadness and grief,focuses on details of all possible
medical procedure.

54. UNDOING
Undoing is the attempt to take back an unconscious behavior or
thought that is unacceptable or hurtful.
• A person tries to 'undo' an unhealthy,destructive or otherwise
threatening thought by engaging in contrary behavior.
• By “undoing” the previous action, the person is attempting to
counteract the damage done by the original comment,hoping the
two will balance one another out.
• Ex. A man gives her wife a bunch of roses after their argument
last night

55. IDEALIZATION
• Valuing something more than it is
worth/attributing exaggerated positive qualities
to self or others.
• Example:
• A lover speaks in glowing terms of the beauty and
intelligence of an average-looking who is not very
bright.

56. COMPENSATION
What you do:
• Develop or strengthen positive traits to make up for
limitations
• Distract attention from the weaknesses
Examples:
• Weak in school, excellent in sports.
Problems:
• Unbalanced
• Incompetent in some areas

57. MATURE DEFENCE MECHANISM

58. ALTRUISM
• Dealing with stressors by dedicating
oneself to meeting the needs of others.
• Constructive service to others that brings
pleasure and personal satisfaction.
• Example:A person whose parents died of
cancer forms an organization to deal with
patients suffering from cancer and
providing treatment free of cost.

59. HUMOR
Using comedy to overtly express feelings and
thoughts without personal discomfort and without
producing an unpleasant effect on others.
Freud suggested that "Humour can be regarded as
the highest of these defensive process’’.
Example:A man who is about to be executed,the
firing squad leader offers the man a cigarette.He
replies,”No thanks,I am trying to quit”.
It’s okay if I lost a leg at
least I can dress up like a
pirate now
hahahahahhahahahahah
a

60. SUBLIMATION
Transformation of unwanted impulses into
something less harmful.
• This can simply be a distracting release or
may be a constructive and valuable piece of
work.
• Sublimation is probably the most useful and
constructive of the defense mechanisms as it
takes the energy of something that is
potentially harmful and turns it to doing
something good and useful.

61. SUBLIMATION
Freud believed that the greatest achievements
in civilization were due to the effective
sublimation of our sexual and aggressive urges
that are sourced in the Id and then channeled
by the Ego as directed by the Super ego.
• Example - A angry man does pushups
to work off his temper.

62. ANTICIPATION
• Dealing with stressors by anticipating the
consequences and feelings associated with
possible future events and considering
realistic solutions.
• Ex: getting old –think ahead and plan your
retirement wisely!

63. SUPPRESSION
• Conscious decision to postpone attention to an
impulse or conflict.
• The suppressed content temporarily resides in
the unconscious.
• Example:
• Focusing on studying for the exam and not
worrying about job opportunities after
passing at the moment.

64. OMNIPOTENCE
• Acting superior to others,as if one possessed special powers or abilities,to
artificially prop-up self-esteem.
• Example:
• Someone acts self assured and asserts’I can handle anything attitude,in the face of
obviously doing a doubtful or poor job of dealing with his own problem.

65. MEASUREMENT OF DEFENSE MECHANISMS
• Defense Mechanism Test (Kragh, 1955)
• Defense Style Questionnaire (Bond et al, 1983)
• Defense Mechanisms Rating Scale (Perry, 1989)
• Clinical Vignette Method (Valliant, 1976)
• Defense Mechanism Inventory (Gleser & Ihilevitch, 1969)

66. DEFENCE MECHANISM IN PSYCHIATRIC
DISORDERS

67. SR.NO. Disorder Defense mechanisms
1. Anxiety Repression
2. Phobia Displacement
Regression
3. OCD Isolation of affect
Undoing
Reaction Formation
4. Depression Regession
Turning of regression against
self
5. Mania Denial
Projection
Regession
6. Paranoid Projection
Regression
Rationalization
7. Schizophrenia Regression
Projection
Isolation of affect

68. Sr. no. Personality disorder Defense mechanisms
1. Cluster A Fantasy
Projection
2. Cluster B Acting out
Splitting
Dissociation
Devaluation
3 Cluster C Passive aggression

69. • Anxiety: When repression proves to be inadequate, previously contained
primitive instinctual urges threaten to come to expression and this threat creates
the sense of apprehension characteristics of anxiety.
• Phobia: Through the mechanism of displacement a phobia replaces anxiety.
Regression is inherent as phobia involves return to primitive mode of thought
through which child copes with his own threatening impulses.
• Mania : Denial is the defense mechanism characteristic of mania. When denial
is threatened patient may then resort to Projection - attributing his own anger to
others. Regression- return to the magical thinking characteristic of a small child.

70. OCD :
• Isolation of affect is responsible for the symptom of obsessional thoughts,
Undoing creates compulsive acts (a ritual which magically undoes a forbidden
unconscious impulse) and Reaction formation(development of attitudes opposite
to the impulses being defended against) accounts for scrupulosity and other
exaggerated characteristics of cleanliness.
Depression :
• In less severe form of depression, that is depression out of proportion to the
reality of the loss, the loss produces regression and revives the intense sense of
hopelessness and despair that a small child experiences.In extreme depression the
effect of identification with the lost object and the use of the mechanism of
turning aggression against the self.

71. TAKE HOME MESSAGE
• Defence mechanism is unconscious mental processes employed by the ego to reduce anxiety.
• At each phase of libidinal development ,specific drive component evoke characteristic ego defenses.
• George Valliant classified defense mechanism into four types:
Narcissistic
Immature
Neurotic
Mature
• Defence mechanism are associated with various psychiatric disorder thereby its identification helps to
reach at a diagnosis.

72. REFERENCE
• KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK OF
PSYCHIATRY T E N T H E D I T I O N
• Kaplan & Sadock's Synopsis Of Psychiatry - 11Edition