JOURNAL CLUB PRESENTATION

DEPARTMENT OF CLINICAL
PSYCHOLOGY, MGMCH

PRESENTED BY:
MS. VISHAKHA JAISWAL
M. PHIL CLINICAL PSYCHOLOGY

SUPERVISED BY:
MS. MAHAK MATHUR
ASSISTANT PROFESSOR
THE ROLE OF DEFENSE MECHANISMS IN
EMERGING PERSONALITY DISORDERS IN
CLINICAL ADOLESCENTS

PSYCHIATRY
PUBLISHED: 29th March, 2019

AUTHORS: Mariagrazia Di Giuseppe,

Alessandro Gennaro, Vittorio Lingiardi
& J. Christopher Perry

DOI: 10.1080/00332747.2019.1579595
INTRODUCTION
 DEFENSE MECHANISMS
Defense mechanisms are unconscious strategies that people employ with the primary goal of relieving themselves of
anxiety, and other unpleasant emotions, feelings and thoughts.

Freud posited that the personality is comprised of three basic components: the id, the ego, and the superego. It is the
ego's responsibility to mediate between the id and the superego, which often results in stress. Consequently, the ego
finds itself negotiating self-control of the id, at the same time inducing the more flexible approach of a rigid
superego. As such, the ego resorts to implementing a variety of means to handle its discomfort in the form of defense
mechanisms (Freud, 1894).

Defense mechanisms are unconscious ego defenses employed when the ego feels threatened or overwhelmed by the
demands of the id and superego. These defenses may be healthy or unhealthy, mature or immature. No matter their
orientation, they are natural psychological responses outside a person's control, useful in reducing internal conflict
that affects behavior (Freud, 1894).
In 1936, Anna Freud published perhaps her most influential book: The Ego and the Mechanisms of Defense (A. Freud,
1937). In order to understand how the ego uses defense mechanisms, it is necessary to understand the
defense mechanisms themselves and how they function.

Some defense mechanisms are seen as protecting us from within, from the instinctual impulses of the id
(e.g., repression); other defense mechanisms protect us from external threats (e.g., denial).

To help understand these issues, Anna Freud identified and discussed ten defense mechanisms as being
commonly recognized in the field of psychoanalysis: regression, repression, reaction-formation, isolation,
undoing, projection, introjection, turning against the self, reversal, and sublimation (Freud, 1937).
 PERSONALITY DISORDERS
Personality disorders are a group of mental disorders. They involve long-term patterns of thoughts and
behaviors that are different from what is considered normal in your culture. The thoughts and behaviors
are unhealthy and inflexible. They cause serious problems with relationships, work, and social activities.
● Antisocial personality disorder: a pattern of disregarding or violating the rights of others. A person with
antisocial personality disorder may not conform to social norms, may repeatedly lie or deceive others, or may
act impulsively.
● Avoidant personality disorder: a pattern of extreme shyness, feelings of inadequacy, and extreme sensitivity
to criticism. People with avoidant personality disorder may be unwilling to get involved with people unless
they are certain of being liked, be preoccupied with being criticized or rejected, or may view themselves as
not being good enough or socially inept.
● Borderline personality disorder: a pattern of instability in personal relationships, intense emotions, poor
self-image and impulsivity. A person with borderline personality disorder may go to great lengths to avoid
being abandoned, have repeated suicide attempts, display inappropriate intense anger, or have ongoing
feelings of emptiness.
● Dependent personality disorder: a pattern of needing to be taken care of and submissive and clingy behavior.
People with dependent personality disorder may have difficulty making daily decisions without reassurance
from others or may feel uncomfortable or helpless when alone because of fear of inability to take care of
themselves.
● Histrionic personality disorder: a pattern of excessive emotion and attention-seeking. People with histrionic
personality disorder may be uncomfortable when they are not the center of attention, may use physical
appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions (APA, 2013).
● Narcissistic personality disorder: a pattern of need for admiration and lack of empathy for others. A person
with narcissistic personality disorder may have a grandiose sense of self-importance, a sense of entitlement,
take advantage of others or lack empathy.
● Obsessive-compulsive personality disorder: a pattern of preoccupation with orderliness, perfection and
control. A person with obsessive-compulsive personality disorder may be overly focused on details or
schedules, may work excessively, not allowing time for leisure or friends, or may be inflexible in their morality
and values.
● Paranoid personality disorder: a pattern of being suspicious of others and seeing them as mean or spiteful.
People with paranoid personality disorder often assume people will harm or deceive them and don’t confide in
others or become close to them.
● Schizoid personality disorder: being detached from social relationships and expressing little emotion. A
person with schizoid personality disorder typically does not seek close relationships, chooses to be alone and
seems to not care about praise or criticism from others.
● Schizotypal personality disorder: a pattern of being very uncomfortable in close relationships, having
distorted thinking and eccentric behavior. A person with schizotypal personality disorder may have odd beliefs
or odd or peculiar behavior or speech or may have excessive social anxiety (APA, 2013).
REVIEW OF LITERATURE
 AUTHORS YEAR FINDINGS

Perry, Petraglia, Olson, 2012 Defenses at the lower hierarchical levels are maladaptive, although in certain
Presniak, & Metzger circumstances they become essential to protect the individual from awareness
of stressors, anxiety, and associated conflicts

Bond & Perry 2004 Higher defense mechanisms maximize awareness of internal and external
stressors, modulate the expression and gratification of wishes and needs, and
provide a sense of freedom to choose

Cramer 2009 The nature of an individual’s defensive functioning is related to a number of

factors, such as age, gender and IQ

Cramer 2012 Empirical evidence has supported the notion that specific defense mechanisms
become predominant at different stages in development

Diehl et al. 2014 Defensive functioning is related to personality traits/disorders and that
specific defense mechanisms influences the overall psychological functioning
and the adjustment to stressful events
METHODOLOGY
 The research aimed at exploring the developmental and
personality approaches to defenses.

RATIONALE AND It aimed to detect possible associations between age, gender,

and defense mechanisms, focusing on the relationship among
defenses and the development of specific personality
traits/disorders in a clinical adolescent sample.

AIM The systematic investigation of defense mechanisms provides

useful information to enhance our understanding of symptoms
and dysfunctional patterns in emerging personality disorders
(Bond & Perry, 2004) and useful information for conducting
treatment.

HYPOTHESES:

1st hypothesis- Ontogenic development of defense

mechanisms:

Lower-level defenses will be associated with lower age,

although each defense level will follow a specific line of
development due to gender differences and age-gender
interaction.

2nd hypothesis:

Emerging personality disorders in adolescence will show

particular defensive functioning similar to that in adults, and
they will be hierarchically ordered by their defensive and
personality adaptiveness.
SAMPLING AND DATA COLLECTION
➔ 102 self-referred outpatient adolescents recruited from several Child and Adolescent Mental Health
Services (CAMHS) in Central Italy.
➔ Inclusion criterion:
◆ Age 14-18 years
➔ The exclusion criterion:
◆ Psychosis
◆ Intellectual disability
➔ The sample consisted of 51 male and 51 female subjects from ages 14 to 18
➔ A chi square tested the distribution of males and females according to age in the sample, highlighting
no differences, and both the distributions satisfied normal assumptions.
➔ Clinical and Diagnostic Interview (CDI; Westen & Muderrisoglu, 2003)
MEASURES
Defense Mechanisms Rating Scale (DMRS), Shedler Westen Assessment Procedure-200 for
quantitative version Adolescents (SWAP-200-A)

Developed by Jonathan Shedler and Drew Westen in 2003

Developed by J. Christopher Perry in Cambridge in 1981
It is a Q-sort instrument for assessing personality pathology in
an observer-based method that assesses on verbatim adolescents, adapted from the widely used adult version, the
transcripts the use of 30 individual defense mechanisms, SWAP-200 (Westen & Shedler, 1999a, 1999b).
hierarchically ordered in seven defense levels, arranged in a To describe a patient using the SWAP-200-A Q sort, a rater rank
hierarchy from least to most adaptive level of functioning. orders the 200 statements into eight categories of relevance from
0 (irrelevant or not descriptive) to 7 (highly descriptive), on the
Overall Defensive Functioning (ODF): A summary variable of basis of their applicability to the patient.
overall defense adaptiveness
Provides a dimensional diagnosis for:

Good convergent and discriminant validity for the overall (a) 10 personality disorders prototypes (Schizoid, Schizotypal,
hierarchy of defense mechanisms has been demonstrated Paranoid, Antisocial, Borderline, Histrionic, Narcissistic,
(Perry & Hoglend, 1998). Avoidant, Dependent, and Obsessive-Compulsive PD scales), as
described by the DSM-IV

Interrater reliability between trained raters in general is (b) personality scale, namely, High-Functioning (HF),
above 0.80. representing an index of healthy personality.
HIERARCHY OF DEFENSE MECHANISMS
From the least to the most adaptive, defense levels and their functions are:
➔ Action (including defense mechanisms as acting out, passive aggression, and help-rejecting complaining),
dealing with internal or external stressors by action or withdrawal
➔ Major Image-Distortion (including defense mechanisms as splitting of self and others’ image and projective
identification), which eliminates any ambivalence toward an object by distorting all images to one emotional
view
➔ Disavowal (including defense mechanisms as denial, projection, rationalization, and autistic fantasy),
avoiding recognizing specific stressful aspects of reality that may appear clear to an observer
➔ Minor Image-Distortion (including defense mechanisms as omnipotence, idealization of self and others’
image, and devaluation of self and others’ image), distorting the image of the self, body, or others to dismiss
problems and thereby up-regulating self-esteem
➔ Neurotic (including defense mechanisms as repression, dissociation, reaction formation, and displacement),
keeping the person unaware of conflictual needs, desires, and ideas associated to charged feelings while
allowing expression in symbolically meaningful ways
➔ Obsessional (including defense mechanisms as undoing, intellectualization, and isolation of affects),
distancing from potentially threatening feelings, although the person remains cognitively aware and does not
distort related stressors
➔ High-Adaptive (including defense mechanisms as affiliation, altruism, anticipation, humor, self- assertion,
self-observation, sublimation, and suppression), maximizing adaptation to life and allowing the integration
of feelings, ideas, and their consequences.
 PROCEDURES AND DATA ANALYSIS
Procedure:
➔ Patients were interviewed using the Clinical and Diagnostic Interview.
➔ Each interview was recorded and transcribed, then rated by trained and reliable raters using the SWAP-200-A and
the DMRS.
➔ Each evaluation was conducted blind and independently from the others.

Data analysis:
➔ Parametric analyses were performed according to the age and gender normal distribution in our sample.
➔ To test the ontogenetic development of defense mechanisms according to gender and age, a multivariate analysis of Variance
(MANOVA) in which age, gender, and their interaction were independent variables and the DMRS’ Overall Defensive
Functioning (ODF), defense levels and SWAP 200-A’s High Functioning (HF) scale were dependent variables.
➔ The sample was divided into two groups of middle adolescence, namely, all those subjects ranging in age from 14 to 15, and late
adolescence, ranging from 16 to 18, in order to detect the differences between younger and older adolescents.
➔ To test for an association between personality structures and defense mechanisms and to analyze how personality
traits/disorders differ in adaptiveness (Hypothesis 2), Pearson’s correlations were calculated among the SWAP 200-A’s
personality dimensions and DMRS defense levels and Overall Defensive Functioning.
RESULTS
DESCRIPTIVE MEANS OF HIGH FUNCTIONING, ODF AND DEFENSE LEVELS
MANOVA ON DEFENSE MECHANISMS
HYPOTHESIS 1
➔ The Multivariate Analysis of Variance (MANOVA) found a statistically significant effect for gender, age, and
their interaction explaining the dependent variables, namely, Overall Defensive Functioning (ODF), defense
levels, and SWAP 200-A’s High Functioning scale (HF).

➔ Certain defense levels differed by age and gender, reflecting the interaction effect, including Obsessive,
Disavowal, and Major Image-Distortion defenses.
➔ No differences were found among gender, age, or their interaction regarding narcissistic defenses.
➔ By contrast, age was associated with effects on HF, ODF, and Mature defenses, both of which were higher in
older adolescents. Conversely, Action defenses were higher in early adolescence.
➔ Regarding gender, Neurotic defenses were higher in females.
CORRELATIONS BETWEEN DEFENSIVE FUNCTIONING AND PERSONALITY PD SCALES
 HYPOTHESIS 2
Within Cluster A, the Paranoid PD scale had no significant findings. Both Schizoid and Schizotypal PD scales correlated with
using Obsessional defenses, whereas Schizoid scale correlated negatively with Minor Image-Distorting defenses.

Cluster B disorders had positive correlations, ranging from .301 to .900, with immature defense levels (including Action,
Major Image-Distorting, Disavowal, and Minor Image-Distorting), whereas they had mostly negative correlations, ranging
from −.252 to −.891, with Neurotic, Obsessional, and High Adaptive level defenses. Within this group of personality disorder
scales:
➔ Borderline PD was most highly and positively correlated with action and Major Image-Distorting defenses and most
negatively correlated with Obsessional and High Adaptive defenses.
➔ The Histrionic PD scale had a profile similar to Borderline but with correlations of lower magnitudes than BPD.
➔ Antisocial and Narcissistic scales correlated positively with Disavowal and Minor Image-Distorting. Both correlated
nega- tively with Neurotic, Obsessional, and High Adaptive levels, while only the Antisocial PD scale also correlated
positively with Action and Major Image-Distorting levels.
Cluster C disorder scales:
➔ Obsessive-Compulsive PD scale correlated negatively with all four immature defense levels and positively
with Neurotic, Obsessional, and High Adaptive level defenses.
➔ The Avoidant PD scale had a profile similar to OCPD, but of lower magnitude, correlating negatively with
Major and Minor Image-Distorting levels, and positively with Neurotic and Obsessional levels.
➔ Dependent PD also correlated negatively with Disavowal and Minor Image-Distorting levels but diverged in
correlating positively with Major Image-Distorting and negatively with Obsessional level defenses. Moreover,
the Dependent PD scale had high positive correlation with the Neurotic defense level.

The correlations between the ODF and PD scales reveal a hierarchy. From lowest to highest defensive functioning,
they are ordered as follows:
➔ Borderline, Histrionic, Antisocial, and Narcissistic have negative correlations
➔ Paranoid and Dependent have no significant correlations
➔ The remaining Cluster A and C disorders had positive correlations: Avoidant, Schizotypal, Schizoid, and
Obsessive-Compulsive PD scales.
DISCUSSION
 HYPOTHESIS 1
The results confirmed our first hypothesis that the development of defense mechanisms is consistent with an age-related process, thus, some defense
mechanisms are more prominent in specific stages of the development.
In particular, compared to middle adolescence, late adolescence was associated with a higher ODF, primarily due to greater reliance on Obsessional and
High Adaptive levels and lesser reliance on Action, Major Image-Distorting, and Disavowal levels defenses.

Minor Image-Distortion defense mechanisms are prominent in adolescence across the board irrespective of age and gender differences. Facing emotional
conflicts, the adolescent attributes extreme positive or negative qualities to the self or important others, thereby momentarily enhancing self-esteem, while
protecting the self from feelings of powerlessness and unimportance (Perry, 1990). Older males tended to use defenses such as idealization, devaluation,
and omnipotence less than females, suggesting that they resolve some self-esteem issues earlier than females.

Gender differences in adolescents’ defensive functioning were observed. Greater use of Obsessional defense mechanisms in boys leads to a higher level of
adaptiveness and a tendency to be associated with specific personality traits related to the avoidance or control of impulses, feelings, and desires. On the
other hand, greater reliance on Neurotic defenses in girls leads to the development of personality traits associated with self-sacrificing behaviors and
repressiveness.

While no gender difference was found on the Overall Defensive Functioning, age/gender interaction showed instead significant mean difference in the ODF.
The use of Action and Disavowal defenses is prevalent in middle adolescence, with males using more of these defenses than females. Girls show slower
improvement in defensive adaptation, whereas boys decreased reliance on immature defenses in favor of more adaptive defenses earlier than girls did.
 HYPOTHESIS 2
Each personality scale was differentially associated with patterns of defensive functioning in our adolescent sample. The
Personality trait/disorder scales fell into an order vis-à-vis their associations with specific defense levels. This resulted in a
sort of hierarchy of defensive adaptation for the PD types, as reflected in the magnitude of their correlations with ODF.

BPD was the lowest, closely followed by the other Cluster B disorders. These are characterized by an intense use of immature
defenses, externalized behavioral patterns, high levels of impulsivity, aggressiveness, lack of frustration tolerance,
image-distortion, and dysfunctional relationships.

Lack of emotional regulation, considerable problems with aggressiveness, very poor relational skills, identity diffusion, and
deficits in introspective attitude emerge in patients with borderline personality disorders early in adolescence. This often
results in self-destructive behavior and an inability to maintain deep relationships, as reflected in the correlation with Action
and Major Image-Distortion defenses.

Adolescents with a high score on the Histrionic PD scale were still very poor in defensive functioning but their conflicts are
related more to the extreme need of attention and confirmation by the others, as demonstrated by the high correlation with
Major and Minor Image-Distorting defenses.

Adolescents with high scores in the Antisocial PD scale show similar defensive functioning to those receiving high scores on the
Narcissistic PD scale: They are both characterized by wide use of all the immature defenses, resulting in very low adjustment
scores.
The Cluster A and C disorders were in the midrange toward the higher adaptive end of the defensive hierarchy.
➔ Avoidant and Dependent PD scales were not associated only with adaptive or maladaptive defense levels but
rather were characterized by a wide range of defense mechanisms. Defensive flexibility, consisting of the use
of a wide range of defense mechanisms from the least to the most adaptive in the hierarchy, allows the
teenager to deal with developmental tasks in multiple ways, reflecting the adolescent’s functional discovery of
the self and the surrounding world.
➔ Schizoid and Schizotypal PD scales were instead characterized by concrete thinking and literal interpretation
of reality, with difficulty in recognition and expression of personal feelings, as demonstrated by the
correlation with obsessive defense mechanisms.
➔ Obsessive-Compulsive PD scale tended to deal with stressful situations by resorting to high-neurotic and
mature defenses to handle conflictual emotions and thoughts. These adolescents tended to be responsible and
assertive and to have high ethical standards, although the expression of their feelings might be influenced by
their tendency to see themselves as rational and logical persons. The SWAP-OCPD scale suggests that they are
also competitive and use their talents to charm and attract others without being hostile or devaluing, as
proved by the negative correlation with Minor Image-Distortion defenses.

Finally, Westen et al.’s view (2005) of the High Functioning scale as a healthy personality prototype was supported
by its strikingly high convergent correlation with ODF.
CRITICAL ANALYSIS
 STRENGTHS
➔ One of the few studies to have covered the following research areas:
◆ Ontogenesis of defense mechanisms
◆ Emerging personality disorders among adolescents
◆ Defense mechanisms through the lens of developmental tasks of adolescence
➔ Normality of distribution of data allowing the use of parametric tests for statistical analysis leading to more robust
results
➔ The high correlation between HF scale and the defense levels scales in perfect order provides further evidence for the
validity and the reliability for the scales used
➔ Each evaluation was conducted blind and independently from the others, so that each rater did not code more than one
measure for each participant. This ensured further minimisation of rater bias in the research.
➔ The significant results may facilitate the diagnostic process, enhance case formulation, and help in addressing specific
interventions and obtaining information relevant to the process and outcome changes in treatment
➔ As demonstrated in a validation study of the CDI, personality pathology can be reliably assessed by the CDI with a
strong correlation (median r > .80) between interviewer and clinician SWAP-200 diagnoses (Westen & Muderrisoglu,
2003).
 LIMITATIONS

➔ The interview method of data collection introduced bias in the procedure lowering the reliability of
the results
➔ The study was cross-sectional in design and, therefore, could not give a fuller picture of the
ontogenesis of defense mechanism which was its primary aim.
➔ The differences in the two age cohorts could be due to extraneous factors other than development,
such as parents or the participating mental health agencies having different clinical thresholds for
referring younger and older adolescents, which could produce a bias responsible for the observed
differences.
➔ Correlational analysis fails to establish causality between the variables.
➔ Exclusion criteria included ID and psychosis only.
FUTURE
➔ Longitudinal study starting from early
adolescence and going well into
DIRECTIONS middle-late adulthood
➔ Development of more reliable methods to
assess defensive mechanisms and
maladaptive personality variables among
adolescents
➔ Inclusion of variables such as parenting
styles, life experiences and cultural
expectations
➔ Exploring the reason for histrionic traits to
score lower in adaptive functioning than
antisocial and narcissitic traits
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