How psychiatric treatments can enhance psychological defense mechanisms

Dissociation and recovery in psychosis - an overview of the literature

Background

The relationship between dissociation and recovery from psychosis is a new topic, which could attract the interest of the researchers in the field of dissociation due to its relevance to their daily clinical practice. This review brings together a diversity of international research and theoretical views on the phenomenology of dissociation, psychosis and recovery and provides a synthesis by narrative and tabulation of the existing knowledge related to these concepts.

Aims

The objective was to make a synthesis by narrative and tabulation about what is known on the topic.

Methods

The systematic search was conducted according to the PRISMA-statement in the databases Medline, PsycInfo, PubMed and Google Scholar. 2110 articles were selected according to the inclusion and exclusion criteria detailed in the methods, and 19 records were included in the review.

Outcomes

None of the included publications put together, in the same conceptualisation or hypothesis, dissociation and the recovery from an episode of psychosis, therefore this matter remains unstudied at this time.

Conclusion

The process of reviewing the existing scientific literature in the field of dissociation and recovery from psychosis has been very useful for charting the direction that future research will take.

Psychological defense mechanisms among individuals with SCI with adjustment disorder

OBJECTIVES

The used psychological defense styles among individuals with spinal cord injury (SCI) with adjustment disorders (AJD) have not yet been described. In the present investigation, the prevalence of AJD among people with SCI has been estimated and the pattern of used defense styles has been identified.

DESIGN

Cross-sectional investigation.

SETTING

A tertiary rehabilitation center in Iran.

PARTICIPANTS

Individuals referred to Brain and Spinal Cord Injury Research Center were invited to participate in a screening interview. AJD was diagnosed based on DSM-V criteria. Those with AJD diagnosis were scheduled for another interview to assess defense mechanisms.

OUTCOME MEASURES

Demographic and injury-related variables were recorded. Defense mechanisms were assessed by the 40-item version of the Defense-Style Questionnaire (DSQ-40).

RESULTS

Among 114 participants, 32 (28%) were diagnosed with AJD among whom 23 subjects attended the second interview. Mean age and time since injury were 29.57 ± 9.29 years and 11.70 ± 6.34 months, respectively. The majority of patients were using idealization defense mechanism (91.3%). In the second and third place, passive aggression (87.0%) and somatization (82.6%) defense mechanisms were observed, respectively. Neurotic style was dominantly used (11.52 ± 2.26). Sex, marital status, educational level, cause of the injury and injury level were not related to defense style (P: 0.38, 0.69, 0.88, 0.73, and P: 0.32, respectively).

CONCLUSION

Prevalence of AJD is estimated to be 28% among individuals with SCI. The most prevalent defense style was neurotic and the dominant used defense mechanism was "idealization." The role of demographic and injury-related variables in determining the used defense mechanisms was insignificant.

Personality and Defense Styles: Clinical Specificities and Predictive Factors of Alcohol Use Disorder in Women

This study investigated personality traits and defense styles in order to determine clinical specificities and predictive factors of alcohol use disorders (AUDs) in women. A female sample, composed of AUD outpatients (n = 48) and a control group (n = 50), completed a sociodemographic self-report and questionnaires assessing personality traits (BFI), defense mechanisms and defense styles (DSQ-40). Comparative and correlational analyses, as well as univariate and multivariate logistic regressions, were performed. AUD women presented with higher neuroticism and lower extraversion and conscientiousness. They used less mature and more neurotic and immature defense styles than the control group. Concerning personality traits, high neuroticism and lower conscientiousness were predictive of AUD, as well as low mature, high neurotic, and immature defense styles. Including personality traits and defense styles in a logistic model, high neuroticism was the only AUD predictive factor. AUD women presented clinical specificities and predictive factors in personality traits and defense styles that must be taken into account in AUD studies. Implications for specific treatment for women are discussed.

Do spinal cord-injured individuals with stronger sense of coherence use different psychological defense styles?

OBJECTIVES

Although the importance of sense of coherence (SOC) and psychological defense mechanisms (PDMs) in the process of coping has been demonstrated, it has not yet been clarified whether individuals with stronger SOC use specific PDMs.

STUDY DESIGN

Cross-sectional.

SETTING

Iran.

METHODS

Demographic and injury-related variables including injury level, time since injury, American Spinal Cord Association (ASIA) Scale and Spinal cord independence measure-III were collected among individuals with spinal cord injury (SCI). SOC was assessed by the Short-form Sense of Coherence Scale. PDMs were identified using 40-version of the Defense Style Questionnaire.

RESULTS

Neurotic defense style was the most commonly used style especially. The overall most commonly used PDM was 'rationalization', which was used by 95%. Individuals with stronger SOC used more mature style (P=0.001, r=0.52), particularly 'humor' and 'suppression' mechanisms (P<0.0001 and 0.024, respectively). There was a negative correlation between stronger SOC and the use of immature defenses including passive aggression (P=0.001, r=-0.51), acting out (P=0.001, r=-0.48), isolation (P=0.009, r=-0.50), autistic fantasy (P=0.010, r=-0.30) and somatization (P<0.0001, r=-0.62). Married individuals had significantly stronger SOC (P=0.01). Age, gender, age at the time of injury incidence, time since injury, ASIA score and cause of injury were not determinants of SOC.

CONCLUSION

In this study, PDMs, which are more probable to be used by individuals with stronger SOC, have been identified. Mature defenses including 'humor' and 'suppression' are used by stronger SOC more often, whereas immature mechanisms are less likely to be used.

Depression: discrete or continuous?

Elucidating the true structure of depression is necessary if we are to advance our understanding and treatment options. Central to the issue of structure is whether depression represents discrete types or occurs on a continuum. Nature almost universally operates on the basis of continuums, whereas human perception favors discrete categories. This reality might be formalized into a 'continuum principle': natural phenomena tend to occur on a continuum, and any instance of hypothesized discreteness requires unassailable proof. Research evidence for discrete types falls far short of this standard, with most evidence supporting a continuum. However, quantitative variation can yield qualitative differences as an emergent property, fostering the appearance of discreteness. Depression as a continuum is best characterized by duration and severity dimensions, with the latter understood in terms of depressive inhibition. In the absence of some degree of cognitive, emotional, social, and physical inhibition, depression should not be diagnosed. Combining the dimensions of duration and severity provides an optimal way to characterize the quantitative and related qualitative aspects of depression and to describe the overall degree of dysfunction. The presence of other symptom types occurs when anxiety, hypomanic/manic, psychotic, and personality continuums interface with the depression continuum.

Psychosis: a synthesis of motivational and defect perspectives

Based on the evolution of human intelligence and the tremendous cognitive capacities arising from it, we have an innate tendency for the extreme thought content, thought form, and sensory perceptions of psychosis. During the conscious and awake state, cognitive regulatory control processes block these more extreme variants to facilitate reality congruency necessary for adaptive functioning. While asleep there is no need for reality congruency and the cognitive regulatory control processes are deactivated allowing psychotic equivalents to be expressed in dreams. This paper helps synthesize the two dominant perspectives regarding the etiology of psychosis: the neuroscience defect perspective and the psychoanalytic motivational perspective. Regarding the former, defective cognitive regulation arising from certain conditions, such as the deficit state of schizophrenia, allows extreme cognitive distortions, thought form variants, and sensory perceptual experiences to intrude into the conscious and awake state, thereby producing psychosis. Consistent with the psychoanalytic motivational perspective, defensive processes can motivate extreme cognitive distortions, thought form variants and sensory perceptual experiences, and also facilitate their expression by deactivating the relevant cognitive regulatory control processes.

Psychological adjustment one year after the diagnosis of breast cancer: a prototype study of delayed post-traumatic stress disorder

OBJECTIVE. The utilization of a post-traumatic stress disorder (PTSD) diagnostic framework for categorizing the psychological adjustment of breast cancer (BC) patients has been debated. We wanted to study the prevalence of PTSD and predictors for PTSD. DESIGN. The current study is a one-year follow-up of 64 early BC patients. METHODS. PTSD, subclinical PTSD, delayed onset PTSD and several theory-driven predictive variables were examined. RESULTS. Thirteen per cent of the patients showed full symptoms of disease-related PTSD compared with 7% at the initial study (6 weeks after diagnosis). Considerable changes were observed in all PTSD clusters (intrusion, avoidance, and arousal), in most cases representing a decrease in symptom level. Immature defence style, emotional coping, avoidant behaviour, and negative affectivity were all implicated as predicting variables in a hierarchical multiple regression analysis which explained 65% of the variability of PTSD severity one year after diagnosis. CONCLUSIONS. This study highlights the PTSD diagnosis as being highly relevant in oncology settings. Early screening for the above-mentioned four variables may help early identification of the patients most at risk of developing PTSD.

A cognitive regulatory control model of schizophrenia

A puzzling aspect of schizophrenia concerns the relationship between negative and positive symptoms. Perspectives suggesting that they arise from the same pathophysiological process are not consistent with the numerous differences such as treatment response, and the underlying neurochemistry relevant to treatment. Explanations viewing negative and positive symptoms as independent processes or diseases cannot readily account for the typical developmental course of schizophrenia, consisting of a lengthy prodromal phase of negative followed by positive symptoms. A model of schizophrenia is presented positing that negative and positive symptoms are distinct but interrelated processes, with the former bringing forth the latter due to damaged or impaired cognitive regulatory control processes. The extensive cognitive distortions, thought form variants, and sensory perceptual experiences comprising psychosis represent a natural propensity derived from the evolution of human intelligence. To facilitate reality congruency typically necessary for adaptive functioning, cognitive regulatory control processes normally prevent these extreme variants from entering the conscious and awake state. During sleep when there is no need for reality congruency the cognitive regulatory control processes are deactivated and psychotic equivalents are expressed. Psychological defensive functioning can also deactivate these processes and allow psychosis to manifest. The negative symptoms of schizophrenia are seen as arising from diverse neural deficits that impair to varying degrees the cognitive regulatory control processes, thus producing psychosis. The pattern of neural damage determines the negative symptom profile, and the impact on cognitive regulatory control processes influences whether negative or positive symptoms dominate or exist in relatively equal proportions.

Repetitive maladaptive behavior: beyond repetition compulsion

Maladaptive behavior that repeats, typically known as repetition compulsion, is one of the primary reasons that people seek psychotherapy. However, even with psychotherapeutic advances it continues to be extremely difficult to treat. Despite wishes and efforts to the contrary repetition compulsion does not actually achieve mastery, as evidenced by the problem rarely resolving without therapeutic intervention, and the difficulty involved in producing treatment gains. A new framework is proposed, whereby such behavior is divided into behavior of non-traumatic origin and traumatic origin with some overlap occurring. Repetitive maladaptive behavior of non-traumatic origin arises from an evolutionary-based process whereby patterns of behavior frequently displayed by caregivers and compatible with a child's temperament are acquired and repeated. It has a familiarity and ego-syntonic aspect that strongly motivates the person to retain the behavior. Repetitive maladaptive behavior of traumatic origin is characterized by defensive dissociation of the cognitive and emotional components of trauma, making it very difficult for the person to integrate the experience. The strong resistance of repetitive maladaptive behavior to change is based on the influence of both types on personality, and also factors specific to each. Psychotherapy, although very challenging at the best of times, can achieve the mastery wished and strived for, with the aid of several suggestions provided.

Hypomania: a depressive inhibition override defense mechanism

OBJECTIVE

Evolutionary perspectives on bipolar disorders can further our understanding of the origins of these conditions, and assist clinicians in distinguishing normal from abnormal states. Hypomania is unique amongst bipolar conditions in that it seems to have beneficial aspects and can be difficult to diagnose, in contrast to full-blown mania and depression. A theoretical perspective regarding the evolution of hypomania as a defense mechanism is presented.

METHOD

Literature review focused on the fitness reducing aspects of depression and the fitness enhancing aspects of hypomania/mania.

RESULTS

Of all the adversity inherent in depression, inhibition of physical and mental activity-depressive inhibition-has the most detrimental consequences, and throughout our evolution would have significantly reduced fitness. It is proposed that hypomania evolved as a depressive inhibition override defense mechanism, typically operating in a short-term time frame, to restore physical and mental activity to fitness sustaining or enhancing levels. Over-activity and not mood enhancement enabled hypomania to function as a defense mechanism against the fitness reducing state of depressive inhibition. Contributing to depressive inhibition are the Behavioral Activation System (BAS) and the Behavioral Inhibition System (BIS), two basic motivational systems. Depressive inhibition consists to some extent of low BAS and high BIS. As human intelligence evolved cognitions inhibiting BAS and activating BIS became amplified, resulting in intensified depressive inhibition.

LIMITATIONS

A theoretical perspective.

CONCLUSIONS

Given its ability to override depressive inhibition hypomania might be viewed as a natural treatment as opposed to a problem to treat, producing maximal improvement in areas where functioning has suffered the most while typically enhancing social behavior.